New Hampshire Colonoscopy Registry Research Articles

Higher Serrated Polyp Detection Rates Are Associated With Lower Risk of Postcolonoscopy Colorectal Cancer: Data From the New Hampshire Colonoscopy Registry.

We used New Hampshire Colonoscopy Registry data to examine the association between postcolonoscopy colorectal cancer (PCCRC) and sessile serrated detection rates (SSLDRs). We included patients with either a colonoscopy or a CRC diagnosis in the NH State Cancer Registry. PCCRC was any CRC diagnosed ≥ 6 months after index examination. Of 26,901 patients, 162 were diagnosed with PCCRC. The hazard ratio for PCCRC was lowest for patients whose endoscopists had the highest SSLDR quintile (≥6%) (hazard ratio 0.29; 95% confidence interval 0.16-0.50). Endoscopists with higher SSLDRs had lower risks of PCCRC. These data validate SSLDR as a clinically relevant quality measure.

Association of Life Expectancy With Surveillance Colonoscopy Findings and Follow-up Recommendations in Older Adults

Surveillance after prior colon polyps is the most frequent indication for colonoscopy in older adults. However, to our knowledge, the current use of surveillance colonoscopy, clinical outcomes, and follow-up recommendations in association with life expectancy, factoring in both age and comorbidities, have not been studied. To evaluate the association of estimated life expectancy with surveillance colonoscopy findings and follow-up recommendations among older adults. This registry-based cohort study used data from the New Hampshire Colonoscopy Registry (NHCR) linked with Medicare claims data and included adults in the NHCR who were older than 65 years, underwent colonoscopy for surveillance after prior polyps between April 1, 2009, and December 31, 2018, and had full Medicare Parts A and B coverage and no Medicare managed care plan enrollment in the year prior to colonoscopy. Data were analyzed from December 2019 to March 2021. Life expectancy (<5 years, 5 to <10 years, or ≥10 years), estimated using a validated prediction model. The main outcomes were clinical findings of colon polyps or colorectal cancer (CRC) and recommendations for future colonoscopy. Among 9831 adults included in the study, the mean (SD) age was 73.2 (5.0) years and 5285 (53.8%) were male. A total of 5649 patients (57.5%) had an estimated life expectancy of 10 or more years, 3443 (35.0%) of 5 to less than 10 years, and 739 (7.5%) of less than 5 years. Overall, 791 patients (8.0%) had advanced polyps (768 [7.8%]) or CRC (23 [0.2%]). Among the 5281 patients with available recommendations (53.7%), 4588 (86.9%) were recommended to return for future colonoscopy. Those with longer life expectancy or more advanced clinical findings were more likely to be told to return. For example, among patients with no polyps or only small hyperplastic polyps, 132 of 227 (58.1%) with life expectancy of less than 5 years were told to return for future surveillance colonoscopy vs 940 of 1257 (74.8%) with life expectancy of 5 to less than 10 years and 2163 of 2272 (95.2%) with life expectancy of 10 years or more (P < .001). In this cohort study, the likelihood of finding advanced polyps and CRC on surveillance colonoscopy was low regardless of life expectancy. Despite this observation, 58.1% of older adults with less than 5 years' life expectancy were recommended to return for future surveillance colonoscopy. These data may help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.

Colonoscopy Findings in FIT+ and mt-sDNA+ Patients versus in Colonoscopy-only Patients: New Hampshire Colonoscopy Registry Data.

Few studies compare fecal immunochemical test (FIT) and multi-target stool DNA (mt-sDNA) outcomes in practice. We compared colonoscopy yield following FIT+ or mt-sDNA+ tests to colonoscopies without preceding stool tests in the comprehensive population-based New Hampshire Colonoscopy Registry (NHCR). Outcomes were any neoplasia and an ordered outcome: adenocarcinoma, advanced neoplasia (adenoma/serrated polyp ≥ 1 cm/villous/high-grade dysplasia), nonadvanced neoplasia, or normal. Our total sample included 306 mt-sDNA+ (average age ± SD 67.0 ± 7.9), 276 FIT+ (66.6 ± 8.7), and 50,990 colonoscopy-only patients (61.8 ± 8.1). Among average-risk patients (N = 240 mt-sDNA+, N = 194 FIT+, N = 26,221 colonoscopy only), mt-sDNA+ patients had a higher risk for any neoplasia (67.1%) compared with FIT+ (54.6%, P = 0.00098) or colonoscopy (40.8%, P < 0.0001). Severity of findings and histology subtypes differed across the three groups (P < 0.0001 for both), with a higher yield of advanced findings in mt-sDNA+ patients. In particular, clinically relevant serrated polyps (hyperplastic polyps ≥10 mm/traditional serrated adenomas/sessile serrated polyps) were detected at a higher frequency in mt-sDNA+ patients as compared with FIT+ or colonoscopy-only patients. Even after adjustment, patients with positive mt-sDNA [OR = 2.82; 95% confidence interval (CI), 2.00-4.02] or FIT+ tests (OR = 1.67; 95% CI, 1.19-2.36) were more likely to have histologically more advanced findings than colonoscopy alone. At follow-up colonoscopy, mt-sDNA+ tests were more likely to predict neoplasia than FIT+, largely due to increased detection of serrated polyps. Prevention Relevance: Colorectal cancer screening options include colonoscopy and stool-based tests, including the fecal immunochemical test (FIT) and the multi-target stool DNA (mt-sDNA) test which, if positive, must be followed by a colonoscopy. Assessing "real-world" outcomes of colonoscopies following positive stool tests can inform their clinical use. See related Spotlight, p. 417.

Clinically significant serrated polyp detection rates and risk for postcolonoscopy colorectal cancer: data from the New Hampshire Colonoscopy Registry

Higher adenoma detection rates reduce the risk of postcolonoscopy colorectal cancer (PCCRC). Clinically significant serrated polyps (CSSPs; defined as any sessile serrated polyp, traditional serrated adenoma, large [≥1 cm] or proximal hyperplastic polyp >5mm) also lead to PCCRC, but there are no data on associated CSSP detection rates (CSSDRs). We used data from the New Hampshire Colonoscopy Registry (NHCR) to investigate the association between PCCRC risk and endoscopist CSSDR. We included NHCR patients with 1 or more follow-up events: either a colonoscopy or a colorectal cancer (CRC) diagnosis identified through linkage with the New Hampshire State Cancer Registry. We defined our outcome, PCCRC, in 3 time periods: CRC diagnosed 6 to 36 months, 6 to 60 months, or all examinations (6 months or longer) after an index examination. We excluded patients with CRC diagnosed at or within 6 months of the index examination, with incomplete examinations, or with inflammatory bowel disease. The exposure variable was endoscopist CSSDR at the index colonoscopy. Cox regression was used to model the hazard of PCCRC on CSSDR controlling for age, sex, index findings, year of examination, personal history of colorectal neoplasia, and having more than 1 surveillance examination. One hundred twenty-eight patients with CRC diagnosed at least 6 months after their index examination were included. Our cohort included 142 endoscopists (92 gastroenterologists). We observed that the risk for PCCRC 6 months or longer after the index examination was significantly lower for examinations performed by endoscopists with CSSDRsof 3% to<9% (hazard ratio [HR], .57; 95% confidence interval [CI], .39-.83) or 9% or higher (HR, .39; 95% CI, .20-.78) relative to those with CSSDRs under 3%. Our study is the first to demonstrate a lower PCCRC risk after examinations performed by endoscopists with higher CSSDRs. Both CSSDRs of 9% and 3% to<9% had statistically lower risk of PCCRC than CSSDRs of<3%. These data validate CSSDR as a clinically relevant quality measure for endoscopists.

S254 How Well Do the U.S. and European Surveillance Guidelines Discriminate High- and Low-Risk Groups: Data From the New Hampshire Colonoscopy Registry

Introduction: Surveillance colonoscopy guidelines were updated by the European Society of Gastrointestinal Endoscopy (ESGE) and the United States Multi-Society Task Force (USMSTF) for Colorectal Cancer Recommendations in 2020. Our goal was to use the New Hampshire Colonoscopy Registry (NHCR) to evaluate the ability of the USMSTF (3 year) and ESGE guidelines to discriminate high versus low risk groups for metachronous colorectal neoplasia. We also examined the impact of adding polyp specific groups from the USMSTF 5-year recommendations to the USMSTF 3-year on performance. Methods: We risk stratified NHCR patients who had an index and follow up colonoscopy at least 12 months later as per USMSTF and ESGE guidelines based on index findings. We excluded examinations that were incomplete, had poor bowel preparation, baseline CRC, IBD, or polyposis syndromes. The outcome was the metachronous risk for significant colorectal neoplasia (advanced adenomas, CRC, and large serrated polyps). The sensitivity, specificity, and c-statistic were calculated for each guideline recommendation group. The c-statistics were calculated using probabilities from a logistic regression adjusting for age, sex, and time to follow up. Results: We included 20972 patients (average age 58.8 ± 8.6, 48.1% male). The addition of villous histology to ESGE resulted in an increase in sensitivity but decrease in specificity. The addition of other polyp groups into USMSTF 3 years yielded c-statistics ranging from 0.600 to 0.611. The addition of 1-2 small SSPs into USMSTF 3 years resulted in a 4.1% increase in sensitivity, with only a 1.9% decrease in specificity (Table 1). Conclusion: The ESGE and USMSTF guidelines had similar modest c-statistics, suggesting similar discriminating ability to predicting metachronous neoplasia. This is further suggested by the similar sensitivities and specificities with the addition of villous histology into the ESGE category. Additionally, the modest c-statistics may indicate the need for further adjustment of the guidelines or use of other markers. Further examination of the USMSTF 3-year guidelines were notable for increasing sensitivities with the addition of 1-2 SSPs, suggesting that SSPs may be important predictors of future neoplasia and therefore may need further study for modifications of the guidelines. For example, perhaps 1-2 SSPs should have a 3-year interval.Table 1.: Comparison of ESGE and USMSTF guidelines for metachronous colorectal neoplasia

ID: 3517867 COMPARISON OF COLONOSCOPY FINDINGS IN PATIENTS WITH PRECEDING FIT POSITIVE AND MT-SDNA POSITIVE TESTS TO PATIENTS HAVING A COLONOSCOPY ONLY: DATA FROM THE NEW HAMPSHIRE COLONOSCOPY REGISTRY

There are few comparisons of fecal immunochemical test (FIT) and multi-target stool DNA (mt-sDNA) screening test outcomes in clinical practice. We compared the yield of colorectal neoplasia in colonoscopies of patients with preceding FIT+ or mt-sDNA+ tests to findings for those presenting for screening colonoscopy without a preceding positive stool test in the New Hampshire Colonoscopy Registry (NHCR), a comprehensive statewide population-based colonoscopy database.

S0337 Increased Risk of Left-Sided Advanced Colorectal Neoplasia but Not Serrated Polyps in Adults Less Than 50 Years Who Present With Bleeding: Data From the New Hampshire Colonoscopy Registry

INTRODUCTION: Data regarding advanced neoplasia and serrated polyps (SPs) in adults <50 years of age who present with bleeding are vital for screening and diagnosing CRC in adults <50. We used data from the New Hampshire Colonoscopy Registry (NHCR) to compare the anatomical location of advanced neoplasia and SPs in average risk patients to those who present with bleeding. METHODS: An average risk screening equivalent cohort was created for the analysis. Since many adults <50 have diagnostic exams, we formed an “average risk” sample by selecting diagnostic exams with indications that are associated with a low risk for advanced neoplasia such as change in bowel habits (e.g., constipation) and abdominal pain (Cha et al GIE 2015) and combining these with screening exams. We excluded higher risk indications from this cohort (e.g., anemia or bleeding) as well as surveillance, family history of first degree relative with CRC, IBD, incomplete exams, and poor bowel prep. We compared outcomes for the average risk equivalent group to our group of interest, i.e., exams with bleeding indications. Outcomes were advanced neoplasia (adenomas >1 cm, with villous elements, HGD, and CRC) and clinically important SPs ((HP > 1 cm), any sessile serrated polyp and traditional serrated adenomas) as stratified by anatomical location, left sided (distal to splenic flexure) and right sided (proximal to descending colon). We present absolute and adjusted risks for advanced neoplasia and SPs. Covariates were age, sex, smoking and BMI. RESULTS: There were 5855 NHCR average risk patients <50 years (avg age 38.5 yrs) and 2814 with bleeding (37.6 yrs). The absolute and adjusted risks for left sided advanced neoplasia were significantly higher for patients with bleeding than those in the average risk equivalent group (OR = 1.73 95% CI: 1.28–2.34) (Table 1). The increased risk was especially high for left sided CRC (OR = 4.82 95% CI 1.47–15.81). Conversely there was no increased risk for right sided advanced neoplasia, CRC or proximal or distal SPs. CONCLUSION: Young patients with bleeding had an increased risk for left sided advanced neoplasia. These data support current recommendations that patients <50 with bleeding should undergo evaluation for colorectal neoplasia, especially of the left side of the colon. However, there was no increased risk for SPs or right sided neoplasia or CRC in young individuals with bleeding, highlighting a clinically relevant difference in outcomes that may affect choice of testing options for this group.Table 1.: As compared to the average risk screening equivalent group, there was an increased risk for left sided neoplasia including CRC but not for right sided neoplasia or serrated polyps at any location

Increased risk of metachronous large serrated polyps in individuals with 5- to 9-mm proximal hyperplastic polyps: data from the New Hampshire Colonoscopy Registry

Because data on metachronous risk for patients with index proximal 5- to 9-mm hyperplastic polyps (HPs) are limited, the clinical significance of these polyps is unclear. Conversely, published data suggest that sessile serrated polyps (SSPs), traditional serrated adenomas (TSAs), and large (≥1 cm) HPs are high-risk lesions requiring close surveillance. We used data from the New Hampshire Colonoscopy Registry (NHCR) to examine the risk of metachronous large SPs and advanced neoplasias (ANs) in patients with 5- to 9-mm proximal HPs. We included adults with at least 1 polyp resected at index colonoscopy and a surveillance examination 12 months or more after index. Outcomes were risk for metachronous large (≥1 cm) SPs and ANs (≥1 cm, villous elements, high-grade dysplasia, or colorectal cancer [CRC]). Individuals were hierarchically stratified by the most significant index SP. The risks for adults with proximal 5- to 9-mm HPs at index examination were compared with individuals with index findings of large (≥1 cm) HPs or any SSPs or TSAs, nonsignificant HPs (<1 cm in rectosigmoid or<5mm anywhere in colon), high-risk adenomas (AAs or≥3 adenomas, no SPs), and low-risk adenomas (no SPs). We present absolute and adjusted risks of metachronous polyps from a regression model that included age, sex, body mass index, smoking, previous polyp history, family history of CRC, year of diagnosis, endoscopist SP detection rates, and months to surveillance examination. A total of 8560 NHCR participants were included (44.8% women; average age, 59.0 years; standard deviation, 9.1). Similar to those with large HPs or any SSPs/TSAs at index examination (odds ratio, 7.63; 95% confidence interval, 4.78-12.20), individuals with proximal 5- to 9-mm HPs had an elevated risk for metachronous large SPs (odds ratio, 4.77; 95% confidence interval, 2.54-8.94) as compared with adults with low-risk conventional adenomas. NHCR data suggest that similar to adults with large HPs or any SSPs or TSAs at index examination, individuals with index 5- to 9-mm HPs proximal to the sigmoid are at an increased risk for metachronous large SPs. These novel data suggest that close surveillance intervals may be appropriate for patients with 5- to 9-mm proximal HPs.

Impact of Colonoscopy Bowel Preparation Quality on Follow-up Interval Recommendations for Average-risk Patients With Normal Screening Colonoscopies: Data From the New Hampshire Colonoscopy Registry.

National guidelines for colonoscopy screening and surveillance assume adequate bowel preparation. We used New Hampshire Colonoscopy Registry (NHCR) data to investigate the influence of bowel preparation quality on endoscopist recommendations for follow-up intervals in average-risk patients following normal screening colonoscopies. The analysis included 9170 normal screening colonoscopies performed on average risk individuals aged 50 and above between February 2005 and September 2013. The NHCR Procedure Form instructs endoscopists to score based on the worst prepped segment after clearing all colon segments, using the following categories: excellent (essentially 100% visualization), good (very unlikely to impair visualization), fair (possibly impairing visualization), and poor (definitely impairing visualization). We categorized examinations into 3 preparation groups: optimal (excellent/good) (n=8453), fair (n=598), and poor (n=119). Recommendations other than 10 years for examinations with optimal preparation, and >1 year for examinations with poor preparation, were considered nonadherent. Of all examinations, 6.2% overall received nonadherent recommendations, including 5% of examinations with optimal preparation and 89.9% of examinations with poor preparation. Of normal examinations with fair preparation, 20.7% of recommendations were for an interval <10 years. Among those examinations with fair preparation, shorter-interval recommendations were associated with female sex, former/nonsmokers, and endoscopists with adenoma detection rate ≥20%. In 8453 colonoscopies with optimal preparations, most recommendations (95%) were guideline-adherent. No guideline recommendation currently exists for fair preparation, but in this investigation into community practice, the majority of the fair preparation group received 10-year follow-up recommendations. A strikingly high proportion of examinations with poor preparation received a follow-up recommendation greater than the 1-year guideline recommendation. Provider education is needed to ensure that patients with poor bowel preparation are followed appropriately to reduce the risk of missing important lesions.

Young adults and metachronous neoplasia: risks for future advanced adenomas and large serrated polyps compared with older adults

Recent increases in colorectal cancer (CRC) incidence in adults younger than 50 years of age have led to more colonoscopies in this age group. As a result, there may be an increasing number of adults<50 years old with polyps detected. There is concern that younger adults may require closer follow-up. Our goal was to use data from the New Hampshire Colonoscopy Registry (NHCR) to examine the risk for metachronous advanced adenomas (AAs) and large (>1 cm) serrated polyps in younger versus older adults who return for a follow-up colonoscopy. Our cohort consisted of NHCR participants with at least 1 polyp on index examination and a follow-up colonoscopy at least 1 year after the index examination. Outcomes were the risks for metachronous AAs (adenomas≥1 cm, with villous elements or high-grade dysplasia, or CRC) and large (≥1 cm) serrated polyps. We present absolute risk and adjusted risks from a logistic regression model stratified by age at index colonoscopy (<40, 40-49, 50-59, and 60+ [reference]). Covariates included index findings, endoscopist adenoma detection rates, sex, smoking, body mass index, follow-up time (months), bowel preparation quality, and family history of CRC. In our sample of 12,380 adults, absolute risk for metachronous AA was lower for younger patients than for patients aged≥60. After adjusting for covariates, when comparing with the 60+ group (reference), the lowest risk was observed in those younger than 40 years (odds ratio, .19; 95% confidence interval, .05-.80). Of note, similar risks were observed in the 40 to 49 age group (odds ratio, .61; 95% confidence interval, .41-.92) and 50 to 59 age group (odds ratio, .71; 95% confidence interval, .58-.86). The risk for large metachronous serrated polyps was not associated with age. Younger adults aged<40 with index adenomas had a lower risk for metachronous AAs than those aged≥60. The 40- to 49-year age group was found to have metachronous risk similar to the 50- to 59-year age group, with both less than the≥60 age group. These data suggest that current surveillance interval guidelines for patients aged≥50 years may appropriately be used with younger adults.

Prevalence of 'one and done' in adenoma detection rates: results from the New Hampshire Colonoscopy Registry.

Background and study aims Adenoma detection rate (ADR), the proportion of an endoscopist’s screening colonoscopies in which at least one adenoma is found, is an established quality metric. Several publications have suggested that a technique referred to as “one and done,” where less attention is paid to additional polyp detection following discovery of one likely adenoma, may be occurring 1 2 3 . To investigate whether this practice occurs and provide additional context to the significance of ADR, we examined ADR by single and multiple adenomas in the statewide New Hampshire Colonoscopy Registry (NHCR). Patients and methods A total of 25,324 NHCR patients receiving screening colonoscopies between 2009 and 2014 by 69 endoscopists were analyzed. ADR was dichotomized into high (≥ 20 %) and low (< 20 %) based on 2006 recommended targets in place during the time of the study. ADR-plus (the average number of adenomas in colonoscopies with > 1 adenoma) was dichotomized at mean values into high (≥ 1.5) and low (< 1.5). As suggested by others, a high ADR but low ADR-plus was used to indicate the “one and done” approach. Results Among endoscopists with an ADR ≥ 20 %, only 5 (7.2 %) had low ADR-plus values and were classified as “one and done.” Results for serrated polyp detection were similar. ADR and ADR-plus decreased monotonically with increasing years since residency ( P values for trend ADR = 0.02; ADR-plus = 0.003) after adjusting for patient risk factors. Conclusion “One and done” infrequently occurred among endoscopists with high ADR in a large statewide registry. The need to replace ADR with other polyp detection metrics (such as ADR-plus) to accurately ascertain performance quality is not supported by these findings.

236 Young Adults With Adenomas: How Does Their Risk for Metachronous Advanced Adenomas Compare With Older Adults?

INTRODUCTION: Recent increases in colorectal cancer (CRC) incidence in adults less than 50 years of age have led to more colonoscopies in this age group. As a result, there is an increasing number of adults &lt;50 with adenomas detected. We used data from the New Hampshire Colonoscopy Registry (NHCR) to explore whether these younger adults with adenomas are at higher risk for future advanced findings than older patients, potentially requiring closer follow-up. METHODS: Our cohort was NHCR participants with at least one adenoma and/or serrated polyp on index exam and a follow-up colonoscopy at least 1 year after the index exam. Outcomes were the absolute and adjusted metachronous risks of advanced adenomas (AA: adenomas &gt;1 cm, with villous elements or high-grade dysplasia, or CRC) and large (&gt;1 cm) serrated polyps (SP). Incomplete exams and patients with IBD or genetic familial syndromes were excluded. We present absolute risk and adjusted risks from a logistic regression model stratified by age at index colonoscopy (&lt;40, 40–49, 50–59, and 60+ (ref)). Covariates include findings on previous and index colonoscopy, sex, smoking, body mass index (BMI), time to follow-up (months), bowel preparation quality, and family history of CRC. RESULTS: Time to follow-up did not vary with age in our sample of 10,116 adults (Table 1). Absolute risk for metachronous AA was lower for younger patients (P &lt; 0.0001) (Table 1), with the lowest risk in patients &lt;40, similar risks in the 40–49 and 50–59 groups, and highest risk in patients &gt;60. Adjusting for covariates did not change findings (P = 0.003). Because younger adults were less likely to have index AAs, we performed a sensitivity analysis, excluding index exams with AAs, and observed no changes in results (P = 0.003). The metachronous risk for large SPs was not significantly associated with age (Table 2). CONCLUSION: Younger adults with index adenomas have a lower risk for metachronous AAs than patients &gt;50. These data suggest that younger adults are not at higher risk for metachronous advanced neoplasia than older adults. The data also suggest that surveillance intervals recommended by current guidelines for adults &gt;50 years may be safe to apply to younger adults.

234 Higher Serrated Detection Rate Is Associated With Lower Risk for Post-Colonoscopy Colorectal Cancer

INTRODUCTION: The serrated pathway may account for a significant proportion of colorectal cancer (CRC). Achieving adequate serrated polyp detection rates (SDR) may reduce the incidence of post colonoscopy CRC (PCCRC). We used data from the New Hampshire Colonoscopy Registry (NHCR) to determine if exams performed by endoscopists who have a clinically significant serrated polyp detection rate (CSSDR) of 7% or greater, proposed by Anderson/Butterly (GIE 2017), had a reduced incidence of PCCRC. In addition, we compared CSSDR to the adenoma detection rate (ADR), the currently used benchmark. METHODS: We defined PCCRC as any CRC diagnosed between 6 and 36 months after an exam with an adenoma on index and between 6 and 60 months following a normal exam. Exclusion criteria were any CRC diagnosed at index or within 3 months, incomplete exams, IBD, and genetic syndromes. Clinically significant serrated polyps (CSSP) were defined as any sessile serrated polyp, traditional serrated adenoma, serrated polyp &gt;1 cm anywhere in the colon and any serrated polyp &gt;5 mm proximal to the sigmoid. CSSDR was defined as number of screening exams with at least one CSSP divided by all screening exams. The exposure variable was a CSSDR of 7% and adenoma detection rate of 25%. Cox regression was used to model the risk of PCCRC in terms of the covariates at index exam. Covariates were age, BMI, smoking, index findings (large serrated polyp, advanced adenoma or any adenoma), followup time (months), bowel prep quality, having more than 1 surveillance exam and family history of CRC. We also compared receiver operating characteristics (ROC) for CSSDR 7% to an ADR 25% using probabilities derived from a logistic regression analysis. RESULTS: In our sample (142,950 index exams) 75 CRCs were diagnosed during the 6–60 month period (45 CRCs diagnosed between 6–36 months) after the index exam. The hazard ratio (HR) for CSSDR of 7% (HR = 0.37 95% CI 0.17–0.83) was similar to that for an ADR of 25% (HR = 0.45 95% 0.23–0.89) (Table 1). The ROCs were similar for CSSDR and ADR and the combination of the 2 rates did not alter the ROC (Table 2). CONCLUSION: Having an exam performed by an endoscopist with a CSSDR of 7% or greater was associated with a decrease incidence of PCCRC (HR = 0.37). The performance of CSSDR and ADR for PCCRC incidence were similar. These data suggest that a CSSDR of 7% or greater may be associated with lower PCCRC rates. However, it may not add an information to that provided by the current primary colonoscopy benchmark, ADR.

238 Prevalence of Advanced Polyps at Age 45–49 Is Similar to 50–54 Years

INTRODUCTION: The American Cancer Society recommends that colorectal cancer (CRC) screening begin at 45 years. To further inform this issue, data on advanced adenoma (AA) and serrated polyp (SP) prevalence in this population are vital. We used the New Hampshire Colonoscopy Registry (NHCR) to examine age related prevalence of advanced findings in an average risk “screening” cohort &lt;50. METHODS: Indications for colonoscopies in adults &lt;50 are often diagnostic. We made the assumption that some indications (e.g., abdominal pain or constipation) might not be associated with increased risk of adenomas. To ensure an appropriate “average risk” population &lt;50, we included only those indications expected to yield AA prevalence rates similar to screening exams, and also tested this assumption. We excluded higher-risk indications, such as GI bleeding, occult blood, Fe deficiency anemia and abnormal imaging. We also excluded surveillance exams, family history of CRC, incomplete exams and poor bowel preparation. AAs were adenomas &gt;1 cm or with villous elements or high-grade dysplasia, or CRC. Clinically significant serrated polyps (CSSP) included large (&gt;1 cm) SPs, any sessile SP or traditional serrated adenoma, and any proximal SP &gt;5 mm. We present prevalence/adjusted risks for AA, adenomas and CSSP. Age was stratified into &lt;40 (reference), 40–44, 45–49, 50–54, 55–59 and 60+ years. Covariates were sex, smoking and BMI. To test our hypothesis regarding indications, we examined the prevalence in screening versus the prevalence in included and excluded indications. We also added the presence of low-yield symptoms as a covariate. RESULTS: In our sample (n = 42,600), AA prevalence increased significantly at 40 yrs. The prevalence of AA and CSSP was similar for ages 45–49 and 50–54. In the model, older age was associated with significantly increased risk for AA and adenomas (Table 2). Older age effect was less pronounced in CSSPs. The prevalence of AA was 4.4% for screening, 3.2% for the included diagnoses and 5.8% for the excluded diagnoses (P &lt; 0.001), supporting our assumption regarding indication. Low-risk symptoms were not associated with an increased risk (OR = 1.03: 0.84–1.13), further confirming our assumption. CONCLUSION: The prevalence of AA increased significantly in the 40–44 group as compared to those &lt;40. The increased prevalence for both AA and CSSP at age 45–49 was similar to that for those 50–54 years. These data support the suggestion that to optimize prevention, screening should begin at 45 years.

Association of small versus diminutive adenomas and the risk for metachronous advanced adenomas: data from the New Hampshire Colonoscopy Registry

Limited data are available to investigate the impact of index adenoma size on the risk of metachronous advanced adenomas. Our goal was to examine the impact of having small (5-9mm) versus diminutive (<5mm) adenomas on the future risk of advanced adenomas within the categories for polyps<1 cm currently used in the United States: 1 to 2 and 3 or more tubular adenomas. We included data from individuals participating in the statewide, population-based New Hampshire Colonoscopy Registry (NHCR). Groups were based on index findings: (1) 1 to 2 adenomas<5mm (both diminutive), (2) 1 to 2 adenomas<1 cm (one or both small), (3) 3 to 10 adenomas<5mm (all diminutive), (4) 3 to 10 adenomas<1 cm (one or more small), and (5) advanced adenomas (AA). AAs were defined as adenomas≥1cm or those with villous elements or high-grade dysplasia or colorectal cancer (CRC). Outcomes were the absolute and adjusted risk of metachronous AAs. Covariates included age, sex, body mass index, family history of CRC, lifestyle factors, presence of serrated polyps, and time since the index examination. After adjusting for the covariates, we observed that having 1 to 2 adenomas with at least one 5 to 9mm adenoma (adjusted odds ratio [AOR], 1.54; 95% confidence interval [CI], 1.12-2.11), 3 to 10 diminutive adenomas (AOR, 1.75; 95% CI, 1.03-2.95), 3 to 10 adenomas<1 cm (1 or more small) (AOR, 2.14; 95% CI, 1.39-3.29) or AAs (AOR, 2.77; 95% CI, 2.05-3.74) were associated with an increased risk for metachronous AA compared with having 1 to 2 diminutive adenomas. A further stratification of group 2 showed that those with exactly 2 small adenomas had an absolute risk of future AA of 7.6% (11/144) (95% CI, 4.3%-13.2%), higher than the absolute risk in the 1 to 2 diminutive polyp group, and similar to the risk for 3 to 10 adenomas of 8.2% (95% CI, 5.4-11.9). For individuals with 1 to 2 adenomas<1 cm, having at least 1 small adenoma increased the metachronous risk of AA compared with having only diminutive adenomas. Furthermore, the subset with 2 small adenomas had a risk of future AA similar to the risk for 3 to 10 adenomas. These data suggest that individuals with at least 1 small adenoma may be at higher risk for future AAs and thus require closer follow-up than those with only diminutive adenomas. These data may be valuable to guideline committees for the creation of future surveillance recommendations.

Smoking and Other Risk Factors in Individuals With Synchronous Conventional High-Risk Adenomas and Clinically Significant Serrated Polyps.

Serrated polyps (SPs) and conventional high-risk adenomas (HRAs) derive from two distinct biological pathways but can also occur synchronously. Adults with synchronous SPs and adenomas have been shown to be a high-risk group and may have a unique risk factor profile that differs from adults with conventional HRAs alone. We used the population-based New Hampshire Colonoscopy Registry (NHCR) to examine the risk profile of individuals with synchronous conventional HRAs and SPs. Our study population included 20,281 first time screening colonoscopies from asymptomatic NHCR participants 40 years or older between 2004-15. Exams were categorized by findings: (1) normal, (2) HRA only (adenomas ≥ 1 cm, villous, high grade dysplasia, multiple adenomas ( > 2) and adenocarcinoma), (3) clinically significant SP (CSSP) only (any hyperplastic polyp ≥ 1 cm, sessile serrated adenomas/polyps or traditional serrated adenomas), and (4) synchronous HRA + CSSP. Risk factors examined included exposure of interest, smoking (never, past, and current/pack years), as well as age, sex, alcohol, education, and family history of colorectal cancer (CRC). Multivariable unconditional logistic regression tested the relation of risk factors with having synchronous HRA + CSSP versus having a normal exam or HRA alone. Among NHCR participants with 18,354 screening colonoscopies (with complete smoking, sex, bowel preparation data, and adequate preparation) there were 16,495 normal; 1309 HRA alone; 461 CSSP alone, and 89 synchronous HRA + CSSP. Current smoking was associated with an almost threefold increased risk for HRA or CSSP, and an eightfold risk for synchronous HRA + CSSP (aOR = 8.66; 95% CI: 4.73-15.86) compared to normal exams. Adults with synchronous HRA + CSSP were threefold more likely to be current smokers than those with HRA alone (aOR = 3.27; 95% CI:1.74-6.16). Our data suggest that current smokers may be at a higher risk for synchronous CSSP + HRA even when compared to having HRA alone.

Endoscopist Specialty Predicts Likelihood of Recommending Cessation of CRC Screening in Older Adults: An Analysis of the New Hampshire Colonoscopy Registry

Introduction: Although the US Preventive Services Task Force recommends that routine CRC screening for adults stop at 75 years, it is not clear what endoscopists are recommending in practice. Our goal was to examine current practice including patient- and endoscopist-related factors associated with cessation of screening in older adults. Methods: We included normal, screening colonoscopy exams in patients ≥ 50 years of age within the New Hampshire Colonoscopy Registry (NHCR), excluding incomplete exams or those with inadequate bowel preparation. We evaluated exams performed by endoscopists with at least 100 screening colonoscopies in NHCR. Primary outcome was endoscopists' recommendation against further screening. Main exposure variables included patient age and endoscopist characteristics. Other variables were patient gender, BMI, family history, smoking, alcohol, exercise, marital status, and education. We used descriptive statistics and chi square test for trend, and performed univariate and multivariable logistic regression models. Results: There were 19,112 normal, screening colonoscopy exams between 2009-2014, of which 4,038 (21%) were in adults age ≥65. These were performed by 73 endoscopists, of which 51 were gastroenterologists, 19 surgeons and 2 family medicine. Median [IQR] adenoma detection rate (ADR) was 24.4% [18.9-29.8]. Nearly 100% of adults aged 65-69 attending screening colonoscopy were recommended to return for another screening colonoscopy in the future (Table 1). Strikingly, only 15% of patients age 70-74 with no FH of CRC were told to stop receiving colonoscopy, while 85% were told to return in 10 years, when they would be 80-84. In univariate analyses, age, FH of CRC, BMI, marital status, endoscopist ADR and specialty were associated with the recommendation to stop colonoscopy (Table 2). In the multivariable model, advancing age and absence of FH of CRC were significantly associated with a recommendation to stop colonoscopy. Gastroenterologists were more likely to recommend stopping colonoscopy in accordance with guidelines than other non-gastroenterology endoscopists (aOR (95% CI) 2.1 (1.4-3.2)).Table: Table. Rates of endoscopists recommending no further CRC screening stratified by patient age and family history of CRCTable: Table. Patient and endoscopists-level factors associated with recommendation of no further CRC screening among adults age 65 and olderConclusion: In a large state-wide colonoscopy registry including 73 endoscopist, the overwhelming majority of patients ≥ age 65 and even age 75 are told to return for screening colonoscopy in 10 years. Having a FH of CRC or non-gastroenterology endoscopist increases the likelihood of being told to return for screening at advanced ages outside of current guideline recommendations.

Risk of Metachronous High-Risk Adenomas and Large (&gt;/= 1 cm) Serrated Polyps in Individuals With Serrated Polyps on Index Colonoscopy: Longitudinal Data From the New Hampshire Colonoscopy Registry

Introduction: There are limited data regarding the metachronous risk of high risk adenomas (HRA) and large (>/=1cm) serrated polyps (SP) in adults with SPs on index colonoscopy. For example, it is unclear if the synchronous presence of SPs and HRA are associated with a greater risk for metachronous HRA or large SPs than HRA or SPs alone. Since large SPs occur infrequently, a large database is needed to address these issues. We used the population based New Hampshire Colonoscopy Registry (NHCR) to examine the risk of metachronous lesions in adults with index SPs characterized by SP size or histology and presence of HRA on index exam. Methods: We used 2 separate schemes to stratify adults by index SPs: 1) SIZE (SPs >/= 1cm vs<1cm) and 2) HISTOLOGY (SSP or TSA vs hyperplastic polyps (HP)). We further stratified SP groups by presence or absence of synchronous HRA (adenoma >/= 1cm, villous, high grade dysplasia, multiple (> 2), cancer). Reference group had no SPs or adenomas. We used logistic regression to adjust for risk factors (age, sex BMI, smoking, f/u time) and calculate 2 metachronous risks: 1) HRA; 2) Large SPs >/=1cm). Results: 5,433 adults (median age 61 yrs; 49.7% men) with 2 colonoscopies (median follow up: 4.9 yrs) (1/04-6/15) were included. Significant SPs alone (large >/=1cm or SSP/TSA) with no synchronous HRA were not predictive of metachronous HRA (Table 1). However, index large SPs or SSP/TSA significantly increased metachronous large SP risk. Synchronous HRA and SSP or TSA at index exam had a higher metachronous HRA risk (OR=12.82) as compared to HRA alone (OR=3.01).Table: Table. Adjusted* odd ratios (95% confidence intervals) for metachronous HRA and large SP (>1 cm) characterized by index HRA and serrated polyp (SP) size and histology among NHCR participants with 2 colonoscopiesConclusion: While index HRA predicted metachronous HRA, adults with only clinically significant SPs and no HRA did not have an increased HRA risk. Since the NHCR afforded us a larger cohort with significant SPs (87 large SPs and 153 SSP/TSA) and no HRAs at index exam than other studies, our data yield a more reliable estimate of minimal HRA risk for adults with only SPs, but further accumulation of data will characterize this risk. Although not linked with metachronous HRA, index clinically significant SPs (large (>/= 1cm) or SSP/TSA) were strongly associated with large SPs. Since large SPs have an increased long term CRC risk (Holme GUT 2015), our data support the continued surveillance of SPs. Finally, synchronous HRA and SSP/TSAs at index significantly increased metachronous HRA risk as compared to index HRA only. This novel finding suggests that adults with HRA and SSP/TSA are a high risk group.

Comparing Risk Factors in Individuals With Conventional High-Risk Adenomas and Clinically Significant Serrated Polyps

Introduction: Serrated polyps (SP) and conventional adenomas derive from two distinct biological pathways with presumably different risk factors. However SPs and conventional adenomas can occur together and published data suggest that adults with both may have a different risk profile than adults with high risk adenomas (HRA) alone. For example, adults with conventional HRA and clinically significant SPs (CSSP; defined below) have a higher risk for metachronous HRA than adults with HRA alone (Schreiner Gastro 2010). We used the population based New Hampshire Colonoscopy Registry (NHCR) to examine the risk profile of individuals with conventional HRAs, CSSPs, and those adults with both HRA and CSSP. Our hypothesis was that current smoking would be strongly associated with having both HRA and CSSP. Methods: We defined HRA as: adenomas >/= 1 cm, villous, high grade dysplasia, multiple adenomas (> 2) and colorectal cancer (CRC). CSSPs included any SPs >/= 1 cm, sessile serrated polyps, traditional serrated adenomas and proximal SPs were >5 mm. Risk factors examined included age, sex, BMI, smoking, alcohol intake, exercise, education level and family history of CRC. We categorized smoking as never, former and current. A multivariable analysis was performed for adults with HRA only, CSSP only and those with both HRA and CSSP. The comparison group were those adults with normal exams. Finally, we did a multivariable analysis comparing adults with both HRA and CSSP to those with HRA only. Results: In the NHCR between 2009-14, we had 20,587 adults with normal exams, 1406 with HRA only, 943 with CSSP only and 154 with HRA and CSSP. Results of the multivariable analyses are shown in Table 1. Higher BMI was associated with a higher risk for HRA as well as CSSP. Older age was a risk factor for HRA only. Current smoking was associated with an approximately 2 fold increased risk for HRA or CSSP and an even greater risk for both HRA and CSSP (aOR=6.43 95% CI: 4.02-10.28) compared to those with no polyps Furthermore, adults with HRA and CSSP were more likely to be current smokers than those with HRA alone (aOR=2.75 95% CI:1.67-4.54; P=0.0003).Table: Table. Risk factors for adults with HRA only ( n =1406), CSSP only ( n =943) and both HRA and CSSP ( n =154)Conclusion: While current smoking is a significant risk for HRA and CSSP individually, current smokers may be at particularly high risk for having both HRA and CSSP. These data suggest that current smokers may benefit from more intense screening given their higher risk for synchronous HRA and CSSP. These findings highlight an area in need of further research.

Should Adenoma Detection Rates Be Adjusted for Smokers and Obese Adults? Data from the New Hampshire Colonoscopy Registry: 2016 ACG Presidential Poster Award

Introduction: Adenoma detection rate (ADR), a quality measure for screening colonoscopies, is associated with protection from interval colorectal cancer (CRC). Currently ADR benchmarks are adjusted for sex only. Obesity and smoking > 20 pack-years were highlighted as important risk factors by the 2009 American College of Gastroenterology CRC Screening Guidelines, but with limited data there are no recommendations to adjust endoscopists' ADR for these factors. We examined the ADR for smokers and obese adults in the New Hampshire Colonoscopy Registry (NHCR).Table 1: Overall and gender specific adenoma detection rates and 95% confidence intervals for patient risk factors among NHCR screening colonoscopies (4/6/2009-9/13/2013))*Methods: The NHCR is a population-based, statewide registry collecting data from endoscopy sites in NH. Prior to colonoscopy, consenting adults complete a questionnaire. Smoking exposure includes current status (never/past/current), # of yrs smoked and # of cigarettes/day, if applicable. We calculated ADR with 95% CI for screening colonoscopies in adults > 50 yrs. The rates were compared by smoking exposure (never vs < 20 pack-years vs > 20 pk-yrs) and BMI (> 30 vs < 30). Results: We analyzed 21,539 screening colonoscopies performed by 77 endoscopists at 20 facilities (4/09 -9/2013). 26% of adults (5423/20,598) had a > 20 pk-yr exposure. 34% (7036/20814) were obese. The ADR for smokers was higher than non- smokers (29.8% vs 21.0%; p < 0.0001). The highest ADR were seen in males with > 20 pk-yrs (35.8%). Obese adults had a significantly higher ADR than non obese adults (26.8% vs 21.8%; p < 0.0001). Conclusion: Among NHCR participants, ADRs for smokers and obese adults are significantly higher than their counterparts without those risks. The difference in ADR between non-smokers and smokers with > 20 pk-yrs was 8.8%, similar to the 10% sex difference in ASGE/ACG benchmarks. Thus, a population of men with a high prevalence of smoking, as observed in Veterans Affairs Medical Centers (72% smokers; Lieberman 2003 JAMA; ADR 37.5% NEJM 2000) might require an ADR or 35% or higher. However, in our sample, despite smokers with > 20 pk-yrs comprising 25% of the NHCR and obese adults comprising 33%, the overall NHCR ADR (23.6%) was consistent with a typical screening population. Endoscopists should be aware of smoking and obesity rates in their practice. Adjusting ADR benchmark goals for these factors, as is currently suggested for sex, may provide optimal protection for some populations where these risks have a high prevalence. However, adjustment for these factors may not be needed for most screening populations.