Colonoscopy Quality and Impact on Cancer Risk: My Experience at Holy Cross

  • Posted Mar 08, 2019
  • hchadmin

By Dr. Patrick Amar

Colon cancer is the third leading cause of cancer death and is preventable in up to 95% of cases. The purpose of a screening colonoscopy is to prevent the occurrence of colon cancer in the future. Without screening of any sort, the likelihood of a patient at average risk of getting colon cancer is 1 in 18. Colonoscopy is a tremendously powerful cancer prevention tool but unfortunately suffers from a number of potential pitfalls. It is both appropriate and critically important for patients and referring providers to inquire about quality measures when selecting a physician to perform colonoscopy.

I have collected data on over 1,500 consecutive colonoscopies which I personally performed over a two-year period. For each of these procedures, I collected data on which portion of the colon was reached, the quality of the bowel preparation, the number of polyps removed and the recommended interval for repeat colonoscopy. For any patient with polyps removed, I subsequently correlated these numbers with their pathology results and revised the polyp counts accordingly, to reflect only those polyps which were found to be adenomatous or serrated. These two particular pathology findings are directly correlated with cancer potential and are the target lesions for which we ask patients to undergo colonoscopy.

The first and most obvious measure in assessing quality of colonoscopy is the rate of completion of the exam. Clearly, examining only a portion of the colon leaves patients at risk for precancerous polyps in the areas not visualized. A colonoscopy is considered complete when the cecum (beginning of the colon) is intubated, as identified by several landmarks. The benchmark minimum recommended standard for this measure is 95% cecal intubation. My cecal intubation rate is 99.6%.

Cecal intubation is not a perfect measure of a complete colonoscopy, however. The cecum can sometimes be mistaken for other parts of the colon, especially the hepatic flexure. This leaves the potential for entire large segments of the colon not to be examined at the time of a colonoscopy. The solution that many gastroenterologists have proposed, to ensure 100% certainty of a complete colonoscopy, is intubation of the end of the small intestine (terminal ileum), which has a distinctly different appearance than the colon on endoscopic evaluation. This also affords the opportunity to evaluate for small bowel pathology which may otherwise be undiscovered (I have diagnosed several cases of Crohn's Disease in this manner). There is no recommended benchmark for intubation of the terminal ileum on screening colonoscopies. Nonetheless, I can proudly say that I have a 98% rate of intubating the terminal ileum for screening colonoscopies, thus dramatically reducing the likelihood of an incomplete examination.

The next and perhaps most important measure in determining quality of colonoscopy over a large number of procedures is the likelihood of discovering precancerous polyps. As noted above, these are either adenomatous or serrated on pathology. Patients with numerous or larger polyps are at an especially increased risk of colon cancer. The measure most commonly used is referred to as Adenoma Detection Rate (ADR), or the percentage of patients who are found to have at least 1 precancerous polyp at the time of screening colonoscopy. The minimum benchmark recommended for adenoma detection rates is 25% among male patients and 15% among females. The national average for ADR is 26% among community physicians and 29% among physicians in academic settings. My personal adenoma detection rate (ADR) is 54%.

The reason that this number in particular matters greatly is that there is tremendous variability in adenoma detection rates among different physicians. A recent study published in the New England Journal of Medicine which examined over 300,000 screening colonoscopies revealed Adenoma Detection Rates ranging from 7.4 to 52.5%. Analysis of this data revealed a dramatic decrease in the likelihood of patients being diagnosed with cancer up to 10 years after their colonoscopy was performed ("interval cancers"), if the performing physician had a higher ADR.  For every 1% increase in adenoma detection rate, patients had a 3% decreased risk of cancer over the following 10 years. Patients undergoing screening colonoscopy by the highest-performing physicians by ADR rates had up to a 69% incremental decrease in "interval cancer" risk compared to the average. This is over and above the baseline reduction in colon cancer risk offered by an "average" colonoscopy.

This measure, however, also has its limitations. The gastroenterology literature discusses the danger of a "one-and-done" colonoscopy. This refers to the tendency for some physicians to overlook adenomas beyond the first one discovered, either due to inattention or in the interest of moving a colonoscopy along. This gives rise to a measure called "adenomas per positive," which refers to the total number of adenomas discovered in patients who had at least one precancerous polyp. This is meant to counteract the tendency for a "one-and-done" colonoscopy and ensure that patients are getting the best cancer protection possible. The published data reveals a national average of 1.9 Adenomas Per Positive among academic centers and 1.65 among community physicians. My personal Adenoma Per Positive rate is 2.44, meaning that in patients who have at least 1 precancerous polyp, the likelihood is that I will find between 1 to 2 additional precancerous lesions.

There are polyp types which do not present an increased risk of cancer to patients. The most common type is a hyperplastic polyp which carries no precancerous potential unless it is part of a specific and rare polyposis syndrome. Likewise, the finding of a "mucosal excrescence" or other benign pathology findings do not represent precancerous tissue and are not counted in a physician's adenoma detection rate. These polyps most frequently occur in the rectosigmoid colon and are often removed by physicians, inadvertently leading many patients to think that they may beat increased risk of colon cancer. Removal of these polyps does not benefit patients in any way and does place them at some increased risk of post-procedure bleeding.

There are a number of key factors which have been found to impact a physician's adenoma detection rate. These include appropriate withdrawal time of the colonoscope during examination of the colon, the quality of the patient's bowel preparation, irrigation and suctioning of any stool residue at the time of examination and appropriate use of available advanced technologies to improve adenoma detection.

The importance of withdrawal time in assessing quality of colonoscopy became widely disseminated approximately 10-15 years ago. It was apparent that there was a tendency for some physicians to rush the colonoscopy examination, thereby decreasing the likelihood of finding precancerous polyps. The recommended minimum average time for withdrawal of the colonoscope was established at 6 minutes, a threshold which correlated with a significantly increased likelihood of finding precancerous polyps.  My personal average for withdrawal time is 8.9 minutes, which would be expected to result in improved adenoma detection. This is also considered the most important measure of quality of colonoscopy examination at the individual procedure level, ensuring that the examination was not compromised by being unduly rushed.

A significant change in the approach to bowel preparation was instituted several years ago, with patients being encouraged to use a "split-dose" bowel preparation regimen. This means that rather than having patients drink the entire bowel preparation on the day prior to the examination, they are instructed to drink the second half of the bowel cleansing solution on the morning of the procedure itself. By decreasing the time interval between administration of laxatives and the performance of the actual procedure, patients have less time to re-accumulate adherent liquid stool on the bowel wall and have improved visualization at the time of colonoscopy. This greatly increases the likelihood of finding either flat or sessile polyps as well as polyps with serrated pathology. I have utilized a split-dose bowel preparation protocol for over 5 years and have noted dramatically improved visibility at the time of colonoscopy. This has resulted in patients having their preparation rated "good" or "excellent" 94% of the time, improving the likelihood of discovering pre-cancerous polyps.

That being said, no patient has a perfect preparation at the time of their colonoscopy. Adherent liquid stool is especially problematic in preventing detection of smaller or sessile polyps. The tendency is simply to examine the colon "as is" and bring patients back at shorter intervals in order to compensate for less than adequate preparation. It is my opinion that once the patient has made an appropriate effort with bowel preparation and has taken the time and expense to have a colonoscopy performed, it is my duty to "clean up" to the best of my ability, within reason. I typically irrigate the colon with a very generous amount of water in order to remove any remaining adherent stool and thereby further improve adenoma detection.

Holy Cross was fortunate to purchase the newest generation colonoscopes from Olympus approximately 5 years ago, namely the 190 series. There is a specific setting on these scopes called Narrow Band Imaging (NBI) which facilitates the discovery of sessile or serrated polyps. Unfortunately, most physicians utilize this setting very little, if at all. I utilize NBI for the entirety of my colonoscope withdrawal, in order to improve adenoma detection rate and can personally attest that it has significantly impacted my ability to find flat or serrated polyps.

Additionally, there has been a tendency to overuse colonoscopy and have patients return at intervals which are shorter than recommended by professional societies. Many physicians developed a tendency to have patient's return for their "five-year" repeat examination, even in situations where bowel preparation was adequate and there were no precancerous polyps discovered. The recommended interval in such circumstances is 10 years. Additionally, when patients are found to have precancerous polyps, the recommended intervals are frequently overly-shortened. Use of appropriate intervals for follow-up colonoscopies after index examinations lowers the patient's individual procedural risk and also lowers the cost to a health system, overall. I am mindful to provide patients with a 10-year repeat interval for normal examinations if I can confidently do so, unless personal risk factors dictate otherwise. Likewise, I strive to adhere to the recommended intervals for follow-up of precancerous polyps, rather than bringing patients back more frequently than they truly require.

Achieving excellence when taking care of patients does not occur in a vacuum or with a single person, however. I work alongside a very dedicated staff of endoscopy nurses, technicians and unit managers. I am also blessed with tremendously talented and hard-working office staff, many of whom have worked with me for over 10 years and share my passion for providing excellent care. It is my sincere hope that I can continue to do so and that our endoscopy unit will continue to strive to be a leader in outstanding patient care with the support of a hospital that I am proud to be affiliated with - Holy Cross.

Dr. Patrick Amar practices with the Holy Cross Medical Group in Fort Lauderdale. He may be reached at 954-928-1778.


Behind the Scrubs: Meet Delia Guaqueta, MD, Hematology / Oncology

  • Posted Oct 10, 2017
  • hchadmin

Sharecare.com spoke with Delia Guaqueta, MD an Oncologist at Holy Cross Hospital in Fort Lauderdale, Florida about why she chose to become an oncologist, how she stays healthy and more.

What made you decide to go into oncology?

I was curious about oncology because you don’t get much exposure to it in medical school. I decided to do an extra rotation to focus on oncology. Through the rotation I realized it was extremely exciting to learn about.

What do you love about your job?

I really love the doctor-patient relationship. You become a part of someone’s family. Although it can be emotionally draining sometimes, you do feel fulfilled, especially when you're able to get someone through treatment and see them with their family enjoying a healthy life.

What do you do to stay healthy?

Personally, I like to fundraise for the American Cancer Society. I try to do a half marathon every year so I spend most of my time training. I start hardcore training six months before. Most people there are running for a family member they lost, or a family member going through treatment. It can become quite emotional. When you cross the finish line you feel so fulfilled. To stay healthy, I also watch what I eat, keeping it as fresh as possible. 

Watch this video to learn more about Dr Guaqueta. 


Breast Cancer Prevention Begins with You

  • Posted Sep 26, 2017
  • hchadmin

Did you know that according to the Centers for Disease Control and Prevention (CDC), breast cancer is the second most common cancer in women in the United States? 

October is National Breast Cancer Awareness month and Holy Cross Hospital would like to take this opportunity to encourage you to care for yourself, and your loved ones, by reminding you of the importance of preventive care.

Thankfully, breast cancer prevention begins with a variety of factors you can control, which include: 

•Managing a healthy weight. Being overweight or obese increases the risk of breast cancer. Eating a healthy diet and getting plenty of exercise can help reduce your risk.

•Breast-feeding. Breast-feeding your children may offer some protection against breast cancer. 

•Hormone therapy. If you're currently taking hormone therapy for menopausal symptoms, ask your doctor about options. According to the National Cancer Institute, long-term combination hormone therapy increases the risk of breast cancer. 

•Restricting alcohol consumption. Your risk of developing breast cancer rises with an increase in alcohol consumption. Limit yourself to no more than one drink a day.

While taking care of your physical health is a great way to help prevent any disease, so is maintaining a healthy spirit. For example:

•Staying positive. Research shows that happiness and optimism are associated with lower rates of breast cancer. Focus on your thoughts — stop negative ones and replace them with positive ones.

•Managing stress. Utilizing a few stress relievers, like deep breathing, muscle relaxation and keeping a journal, can be helpful in controlling the impact stress has on your body.

•Maintaining a balanced lifestyle. Don’t stretch yourself too thin – make sure to have time for proper nutrition, sleep, work and play.

•Creating a circle of support. Maintaining a close network of family and friends can provide you with emotional support when you need it. 

Lastly, getting health screenings and tests from your doctor is key in sustaining your health and helping prevent health conditions like breast cancer. 

Having a primary care physician (PCP) who can coordinate your care is vital to your good health. If you don’t have a PCP, finding one is easy! Just visit your insurance carrier’s website, look for the “find a doctor” area and follow the instructions.  Or use the physician finder at www.holy-cross.com!

Come to our Beyond Breast Cancer event on Thursday, October 5 at the Dorothy Mangurian Comprehensive Women's Center at Holy Cross HealthPlex. Register here or call 954-351-7804.

How can I reduce my cancer risk?

  • Posted Aug 29, 2017
  • hchadmin

Dr. Omar Rashid, Surgical Oncology & General Surgery, offers tips on how to prevent cancer on Sharecare.com.

You can reduce your risk of cancer by following these recommendations for cancer prevention, based on the latest research and international consensus guidelines:

Fitness and weight: Maintain a healthy weight without being underweight.

Sitting is the new smoking: Avoid a sedentary lifestyle and maintain physical activity for 30 minutes a day.

Read more and follow Dr Rashid


Playing It Safe in the Summer Sun

  • Posted Jul 18, 2017
  • hchadmin

Summertime is all about fun in the sun and promoting spiritual health by getting outside to commune with nature.

But, did you know that according to the Skin Cancer Foundation, one in five Americans will develop skin cancer, the most common type of cancer in the United States, and one dies of skin cancer every hour?

With the beautiful weather and days spent outdoors at the park, the beach and the golf course, your skin may be getting more sun exposure now than at other times of the year.

It's a great time to safely take part in outdoor spiritual practices like gardening and spending time in nature. 

While you're enjoying the great outdoors, it’s important to be aware of how much sunlight you get. Ultraviolet (UV) radiation is the main cause of skin cancer and can also cause damage to your eyes. For these reasons, avoiding overexposure to UV light is the simplest form of prevention.

July is UV Safety Month. Here are some simple steps from the Centers for Disease Control and Prevention (CDC) to help prevent overexposure to UV rays:

  • Seek shade, especially during midday hours
  • Cover up with clothing to protect exposed skin
  • Wear a hat with a wide brim to shade the face, head, ears and neck
  • Wear sunglasses that wrap around and block as close to 100 percent of both UVA and UVB rays as possible
  • Put on sunscreen with broad spectrum (UVA and UVB) protection and sun protective factor (SPF) 15 or higher
  • Avoid tanning beds and sunlamps – the UV rays from them are as dangerous as the UV rays from the sun

You can also schedule a skin examination with your health care professional, including your Primary Care Physician (PCP), to catch early signs of cancer before they become a serious threat.

Getting annual physicals and tests from your doctor is key in sustaining your health and preventing disease. Having a PCP who can coordinate your care is vital to your good health. A PCP typically specializes in Family Medicine, Internal Medicine or General Practice.

If you don’t have a PCP, finding one is easy! Just visit your insurance carrier’s website, look for the “find a doctor” area and follow the instructions. Or, let Holy Cross Physician Partners help you.

Photo: courtesy of Sharecare.com

Lung Cancer Screenings $99

  • Posted Feb 22, 2017
  • hchadmin

The Michael and Dianne Bienes Comprehensive Cancer Center is offering a $99.00 Low Dose CT Lung Screening, which includes the radiologist's reading fee!

Where do we call to schedule?  954-202-0277

Who is eligible?  Self-pay patients 

Prescription required? Any M.D. can write a script for a Low Dose CT if the patient meets the criteria.

1.Why get screened?  Early Detection! Lung Cancer causes more deaths than any other cancer.  Of all causes of death, lung cancer ranks second behind heart disease.  The high number of deaths is due to in part to lung cancer being found after it has spread.  CANCER SCREENING can help find lung cancer at an early stage when it can be CURED.

2.Am I at risk for lung disease?  Risk factors include:

  • Tobacco Smoking          
  • Major contact with radon  
  • Contact with asbestos or other cancer-causing agents  
  • Having had certain other cancers
  • Parent, sibling or child with lung cancer•Having had other lung diseases
  • Contact with second-hand smoke

3.Should I start now? Start before cancer symptoms appear. The goal of lung cancer screening is to find lung cancer when treatments will work best.  Treatments usually work best before there are symptoms of cancer.  However, at this time, most lung cancer is found after symptoms appear.

4.Get the best screening test: Low-Dose Computed Tomography (Low-Dose CT).  It is the only screening test proven to reduce the number of deaths from lung cancer.  LDCT takes many pictures of the inside of your chest/lung from different angles using x-rays.  The amount of radiation used is much lower than standard doses of CT.


Holy Cross Expands Access to Cancer Clinical Trials

  • Posted Oct 04, 2016
  • hchadmin

Holy Cross Hospital has been accepted as a member institution into the ECOG-ACRIN Cancer Research Group, which allows our physicians to enroll their patients in clinical trials being conducted in the National Cancer Institute (NCI) Clinical Trials Network.

ECOG-ACRIN was  formed by the merger of the Eastern Cooperative Oncology Group (ECOG) and the American College of Radiology Imaging Network (ACRIN).

The ECOG-ACRIN Cancer Research Group has been awarded a grant by the NCI as a member of the NCI National Clinical Trials Network (NCTN). The ECOG-ACRIN Cancer Research Group is a multidisciplinary, membership-based scientific organization that designs and conducts biomarker-driven cancer research involving adults who have or are at risk of developing cancer.

The Group is dedicated to its stated purpose, which is to achieve research advances in all aspects of cancer care and thereby reduce the burden of cancer and improve the quality of life and survival in patients with cancer. ECOG-ACRIN is comprised of over 1,100 member institutions in the U.S. and around the world. Approximately 12,000 physicians, translational scientists, and associated research professionals from the member institutions are involved in Group research. 




Helpful Tips for Those Living with Skin Cancer

  • Posted Jul 17, 2018
  • Christine Walker

Learning you or a loved one has skin cancer changes your life.

According to the National Cancer Institute (NCI), concerns about treatments, managing side effects and medical bills are common. You may also worry about caring for your family or continuing daily activities.

The NCI and Holy Cross Hospital offer the following suggestions to help you focus on your treatment and maintain a Healthy Spirit:

•    Doctors, nurses, and other members of your health care team can answer questions about treatment, working or other activities. As part of the team's services, you may receive an outreach call. Please remember to return the call if you miss it.

•     Support groups also can help. In these groups, people with skin cancer or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. Groups may offer support in person, over the telephone or on the internet. You may want to talk with a member of your health care team about finding a support group.

When you’re being treated for a health condition, it may not always be easy to decide where to go for care when you need it. For anything that is considered a life-threatening situation (like chest pain or sudden and severe pain) it’s best to go to the emergency department.

For less severe matters that still require immediate attention, if you can’t get in to see your primary care physician (PCP), going to an urgent care facility can save you time and money.

Even if you require emergency or urgent care for your health situation, it’s always best to have a relationship with a PCP who knows your history and understands what is happening with your health over time.

If you don’t have a PCP, just visit your insurance carrier’s website, look for the “find a doctor” area and follow the instructions.


Cardiac Imaging and Radiation Exposure

  • Posted Sep 09, 2009
  • Alan Niederman, MD, FACC, FACP

On August 27, 2009 an article appeared in the NEJM discussing the long term risks of medical imaging utilizing ionizing radiation. This article and its accompanying editorial discuss all testing using ionizing radiation but I will focus on just the cardiovascular issues.

First some background. Radiation damage comes in two ways. 1) Deterministic injury which is usually direct skin damage, sunburn is a good example; and 2)  Stochastic injury, which is the damaging of DNA (think melanoma) and leads to an increased probability of cancer in the future. The background risk of fatal cancer in men is 24% and 20% for women. This dose is cumulative over a lifetime, the higher the cumulative dose the higher the risk of developing a cancer.

We live on a radioactive planet and we all receive 53% of our total radiation from just being here. It ranges from 1.5-2.0 mSv here to 9.0 mSv in Denver. Average across the United States is 3.6 mSv. These figures are yearly. An average chest x-ray is .04mSv so on average we each receive about 90 chest x-rays a year.

This article discusses the large radiation exposure that patients receive from diagnostic cardiac imaging. If your TIMI risk score is low then an approach to the diagnostic work up can be "watchful waiting". Imaging modalities such as stress testing without nuclear imaging and stress testing using echocardiography are also proven to assess cardiac risk and function without radiation.

Nuclear stress testing with the nuclear substance thallium was found to be the highest radiation test giving an average of 15.6 mSv (the equivalent of 173 Chest x-rays). This test alone accounts for 22.1% of the total radiation dose from all study procedures. Diagnostic cardiac catheterization is 7 mSv and for angioplasty about double at 15 mSv. CT cardiac angiography was several times higher than diagnostic cath but has been lowered considerably by the concept of "step and shoot" technique which lowers the dose and was not evaluated in this study as it occurred after the data collection period.

If you have risk but no symptoms it is quite possible that you could have a CT san followed by a nuclear stress test followed by cardiac cath and eventuating in a ptca of your heart artery. Most people could feel that they received state of the art testing and treatment. However as reviewed and discussed in the above cited articles this approach may not be the best approach in individual patients. 

If your physician recommends an imaging test for you should discuss it in detail and understand the total dose of extra radiation that you might receive.


About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

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