A survey of post-polypectomy colonoscopy surveillance knowledge among general practitioners.


 Background
Screening has been shown to be effective in reducing CRC incidence and mortality. Adherence to the guidelines of surveillance after polypectomy is considered key. In most countries including Poland general practitioners (GPs) are responsible for referring patients for surveillance colonoscopy.
The aim of the study was to examine the knowledge of post-polypectomy surveillance among GPs in Poland.
Methods
We have designed five scenarios of post-polypectomy surveillance based on European guidelines adapted by the Polish Society of Gastroenterology. The scenarios described different risk groups based on the characteristics of the removed polyps requiring different time intervals of surveillance colonoscopy. They were supplemented with basic demographic data of the surveyed GP. The questionnaire was carried out by surveyors during a national congress of GPs.
Results
A total of 340 questionnaires were filled by GPs. None of the surveyed doctors gave correct answers in all questions. The knowledge of post-polypectomy surveillance is very unsatisfactory (correct answers 1.2%-55.0%). One year surveillance interval was the most commonly chosen interval regardless risk groups based on the characteristics of the removed polyps. In 4 of 5 scenarios the surveillance overuse ranged 42.1%-98.5%. In a high risk group scenario surveillance was underused in 45.0%.
Conclusions
Post-polypectomy surveillance schemes are not known to GPs with a significant trend towards overuse. Strict adherence to guidelines should be pursued to include written recommendation on surveillance program in the final endoscopy report. Efforts should be made by public health policy makers to increase knowledge of surveillance schemes among GPs.

Background Screening has been shown to be effective in reducing CRC incidence and mortality.
Adherence to the guidelines of surveillance after polypectomy is considered key. In most countries including Poland general practitioners (GPs) are responsible for referring patients for surveillance colonoscopy. The aim of the study was to examine the knowledge of post-polypectomy surveillance among GPs in Poland. Methods We have designed five scenarios of post-polypectomy surveillance based on European guidelines adapted by the Polish Society of Gastroenterology. The scenarios described different risk groups based on the characteristics of the removed polyps requiring different time intervals of surveillance colonoscopy. They were supplemented with basic demographic data of the surveyed GP. The questionnaire was carried out by surveyors during a national congress of GPs.
Results A total of 340 questionnaires were filled by GPs. None of the surveyed doctors gave correct answers in all questions. The knowledge of post-polypectomy surveillance is very unsatisfactory (correct answers 1.2%-55.0%). One year surveillance interval was the most commonly chosen interval regardless risk groups based on the characteristics of the removed polyps. In 4 of 5 scenarios the surveillance overuse ranged 42.1%-98.5%. In a high risk group scenario surveillance was underused in 45.0%. Conclusions Post-polypectomy surveillance schemes are not known to GPs with a significant trend towards overuse. Strict adherence to guidelines should be pursued to include written recommendation on surveillance program in the final endoscopy report. Efforts should be made by public health policy makers to increase knowledge of surveillance schemes among GPs.

Background
Colorectal cancer (CRC) is one of the major causes of morbidity and mortality in developed countries [1,2]. CRC screening has been shown to be effective in reducing CRC incidence and mortality [3,4].
Therefore population-based screening is widely recommended and used in many developed countries [5][6][7]. Due to widespread use of endoscopy screening for CRC, increasing number of people are diagnosed with precancerous polyps. These individuals are considered at increased risk of CRC, and therefore in need for surveillance strategies to prevent future CRC and death from CRC.
Several organizations and professional societies such as European Commission, European Society for Gastrointestinal Endoscopy, British Society of Gastroenterology, American Society for Gastrointestinal Endoscopy issued formal recommendations on colonoscopy surveillance following colorectal polyp removal [7][8][9][10][11]. The Polish Society of Gastroenterology (PSG) adapted the EU guidelines, translated them into Polish and initiated their adoption in Poland in the year 2011 [12]. Adherence to the recommendations is considered key to the efficacy and efficiency of surveillance [13]. Importantly, gastroenterologists', surgeons' or general practitioners' recommendations are the strongest predictor of patient adherence with post-polypectomy surveillance [14,15]. In consequence the European Society for Gastrointestinal Endoscopy recommends in its main recommendations that the endoscopist is responsible for providing a written recommendation for the post-polypectomy surveillance schedule (strong recommendation, low quality evidence) [9]. However, in most countries general practitioners are responsible for referring patients for surveillance colonoscopy. It is therefore not uncommon that patients present colonoscopy results to their general practitioners expecting in-depth discussion of the results and further recommendations including colonoscopy surveillance schedule. They often decide about the surveillance schedule, using endoscopist's written recommendation as a suggestion rather than definite indication. Under-and over-usage of surveillance for each clinical scenario were calculated. Under-and overusage of surveillance were defined as proposed surveillance intervals that were longer or shorter than recommended in the guidelines, respectively. Considering multiplicity of post-polypectomy surveillance guidelines we also compared survey results to the intervals included in ESGE guidelines (published in English in 2013 and were not translated into Polish) [9].
Distribution of answers were also compared between specialty subgroups using Kruskal-Wallis rank test. Statistical analysis was performed using Statistica software (StatSoft Inc.). Statistical significance was considered for p<0.05. Post-polypectomy surveillance is of highest importance as it was suggested that patients who are not enrolled into a surveillance program after colonoscopic polypectomy might have increased risk of CRC [16][17][18][19]. However, it is estimated that 20-30% of endoscopic capacity is occupied by surveillance colonoscopies, approximately the same proportion as primary screening examinations [20][21][22]. It was also demonstrated the less than 25% of screenees receive appropriate surveillance and in 45% the surveillance is overused [18]. In a recent report form Austria adherence to surveillance guidelines among endoscopists is very unsatisfactory [23]. With several European countries initiating populationbased screening programs, the burden of surveillance can be expected to continue increasing, especially with improved adenoma detection related to the improvement in the awareness about quality of colonoscopy [2,24,25]. Although colonoscopy is generally considered as a relatively safe procedure, there exists a risk of major complications including bleeding, perforation and other periprocedural adverse events [26]. Surveillance should be only offered to patients with a substantial residual risk of CRC therefore balancing the potential risks.

Results
Capacity of colonoscopy services is heavily dependent on correct indications and timings for postpolypectomy surveillance [27]. It seems that a large proportion of surveillance procedures are inappropriate in both selection of cases and timing of surveillance, representing both over-and underuse of surveillance [14,15,20,[27][28][29]. In our study we demonstrate an intention of severe overuse of the surveillance with majority of answers indicating a 1 year interval after baseline and surveillance colonoscopy. The overuse of surveillance by GPs might originate form unrecognition of the risk of CRC related to the features of the polyps (ie. number, size, pathology, dysplasia) presented in the scenarios or simply unrecognition of the current guidelines. Considering that there is no trend observed towards postponing surveillance colonoscopy in cases of polyps from intermediate or low risk groups the latter seems more probable. Interestingly the most underuse was found in question one constituting for high risk lesions. In a study of Petruzziello and colleagues form 2012, 69% of post-polypectomy surveillance procedures were inappropriate regarding either timing or indication [20]. Overuse of surveillance results in unnecessary costs and longer waiting times. In one of the studies over 40% of patients with small adenomas had an inappropriately early surveillance examination [30]. Moreover, surveillance is still recommended to patients with clinically irrelevant hyperplastic lesions who do not need any endoscopic surveillance [14,15,20,29]. Underuse poses risk of missing precancerous lesions or early cancers with its medical and legal consequences. For these reasons, the endoscopist should be the professional who recommends the patient on the appropriate surveillance interval. Utilization of electronic reporting systems automatically incorporating surveillance recommendations has been proposed to improve adherence to guidelines [31].
Because of the fact that the final histology result is not available right after the colonoscopy, adequate delivery of the result involving both further recommendations on treatment (if necessary) or surveillance schedule is a resource consuming task. In several settings endoscopies are performed in high volume and high quality centers in distant locations form screenees inhabitance. This might be a discouraging form visiting the endoscopy center again for pathology result pick up. What is more patients might sometimes not be either aware or willing to do it. This is why ESGE recommends that the endoscopist updates and/or finalizes the endoscopy report after receiving the histology report; the updated colonoscopy report should include a written recommendation on the appropriate surveillance, taking into account all endoscopic, histological, and patient-related factors. Adherence to published surveillance guidelines should be monitored as part of a quality assurance program [32].
No statistically significant difference in the structure of answers in specialty subgroup analysis was found in any of the questions. However, highest percentages of correct answers in all the studied scenarios were achieved by family doctors in training. This finding suggests that knowledge of current guidelines is not only abandoned by fully trained family doctors, but also those under training. Therefore, it seems not enough stress is put on postgraduate education in this field.
The strength of this study is the fact that it was a questionnaire directly supervised by the surveyor.
Therefore, use of supplementary materials such as internet printed resources was impossible. On the other hand, the potential bias of the study is the fact that the schedules of post-polypectomy surveillance schemes are not memorized by the GPs and they in such cases may refer to printed or internet resources in search for appropriate surveillance intervals. Additionally, there might be a selection bias due to the fact that the questionnaires were filled by most confident and educated general practitioners while those with less knowledge refused to fill it in. Therefore, the actual recognition of the guidelines might be worse than measured in our study. Percentages may not total to 100 because of rounding. S 1 -five subcentimeter tubular adenomas with low grade dysplasia; high-risk group S 2 -one subcentimeter tubulo-villous adenoma with low grade dysplasia; intermediate risk group S 3 -two subcentimeter tubular adenomas with low grade dysplasia and family history of colorectal cancer; low-risk group S 4 -three subcentimeter hyperplastic polyps; no risk group S 5 -two villous adenomas with low grade dysplasia at first surveillance after removal of high-risk adenoma at baseline Table 2. Structure of a total of 340 answers to individual scenarios of the survey in relation to the specialty of the surveyed GP (percentage of answers). Correct answers were shaded.