Technology Set to Alter Colonoscopy Practices

In response to new technologies and expected decreases in reimbursement for “traditional” procedures, gastroenterologists “will need to change what they do, where they practice, and how they practice,” according to a report issued by the American Gastroenterological Association Institute's Future Trends Committee.

Above all, computed tomographic colonography (CTC) “is likely to become an accepted colorectal cancer screening option within 3 years,” said the report, which was based on expert presentations at a conference convened last spring.

To maintain their practices, gastroenterologists will need to consider new services, which could include providing and interpreting CTC, obesity care, gastroenterological cancer treatment, and natural orifice transluminal endoscopic surgery.

Chronic or difficult-to-treat conditions, like hepatitis and motility and functional disorders, might also assume a bigger role in practice. Nurse-practitioners and physician assistants will likely play larger roles as gastroenterologists “embrace and act on the philosophy that the gastroenterologist is the leader and manager, and not necessarily the direct provider” of digestive disease care, according to the report (Gastroenterology 2006;131:1287–312).

Dr. Timothy C. Wang, who chaired the 10-member consensus development panel, said that CTC will likely be the first technology to take a share of colorectal cancer screening, but that members found it “difficult to predict what percentage of the screening market will shift to CTC.

“Further studies will likely show that CTC is comparable to optical colonoscopy in terms of sensitivity and specificity; however, other advances also may prove to detect polyps.” Also, gastroenterologists “should not completely cede colon imaging to radiologists,” said Dr. Wang, chief of the division of digestive and liver diseases at Columbia University, New York. Some gastroenterology groups have expressed interest in purchasing CT scanners, and the committee recommended that the American Gastroenterological Association (AGA) Institute develop training programs for CTC interpretation.

Gastroenterologists contacted for their perspectives on the report called the conclusions provocative but differed about whether the report is realistic or alarmist.

The report “is thorough and thought provoking … and anything that the AGA Institute can do to raise the level of thought and discussion is laudable,” said Dr. Ronald Vender, professor of medicine at Yale University, New Haven, Conn. “I think the impact [of CTC and other changes] will be much less than they're predicting,” he said, especially when considered from a cost-benefit perspective.

“Colonoscopy rates will probably go up rather than down,” commented Dr. James T. Frakes, professor of medicine at the University of Illinois, Rockford. “But even it that's not the case, gastroenterologists should always be looking for ways to improve and broaden their services,” he said.

“Colonoscopy has become the tail that's wagged the dog,” Dr. John L. Petrini of Sansum Clinic in Santa Barbara, Calif., said. “It's become a huge part of what we do, and I'm not sure it's going to stay that way. … But I don't think that CTC is going to be the one that's a keeper.”

Optical colonoscopy also is getting better, and lesions can be removed immediately in patients who are found to have adenomatous polyps during screening. Avoiding the need for a second procedure makes optical colonoscopy a cost-effective, attractive screening option, he said.

Many patients, said Dr. Douglas K. Rex, professor of medicine at Indiana University, Indianapolis, “will be disillusioned if they have a polyp and have to go on to have another test. … Americans like effectiveness. There will be other effective devices, but it's going to be hard for them to be as effective as colonoscopy.”

There also “hasn't been adequate discussion or education of the public regarding the potential risks of radiation” associated with screening CTC, he added.

Technologies ranging from wireless capsule endoscopy to simplified endoscopes will allow generalists and even nonphysician providers to perform colon surveillance. And over the long term, it will become possible to stratify cancer risk through serum-based proteomics, for example, and genetic or epigenetic markers, eliminating “unnecessary” colonoscopies, the committee said in its report.

One major challenge in CTC interpretation, however, is the presence of significant extracolonic findings in 4.5%–12% of procedures. Direct costs would rise rapidly if all CTCs must be reviewed by radiologists for extracolonic findings after a CTC-trained gastroenterologist has reviewed the colon, the report stated.

Gastroenterologists overall may modify their scope of practice by offering services that don't require extensive retraining. Obesity care may already be too competitive a niche for gastroenterologists to claim, according to those interviewed for this article, but they largely agreed with the committee's conclusion that obesity treatment is a “natural opportunity” for gastroenterologists, especially those who are willing to be part of a multidisciplinary team.

The demand for physicians to treat functional and motility disorders is likely to increase as the population ages. New tools on the horizon should expand and improve the evaluation and management of these disorders.

The same holds true for hepatitis C therapy. “We're only at the tip of the iceberg in taking care of patients with hepatitis C and chronic liver disease,” Dr. Frakes said.

As the committee points out in its report, however, limited reimbursement for such labor-intensive cognitive services means that midlevel providers increasingly will need to be utilized to make services effective and financially viable.

In response to new technologies and expected decreases in reimbursement for “traditional” procedures, gastroenterologists “will need to change what they do, where they practice, and how they practice,” according to a report issued by the American Gastroenterological Association Institute's Future Trends Committee.

Above all, computed tomographic colonography (CTC) “is likely to become an accepted colorectal cancer screening option within 3 years,” said the report, which was based on expert presentations at a conference convened last spring.

To maintain their practices, gastroenterologists will need to consider new services, which could include providing and interpreting CTC, obesity care, gastroenterological cancer treatment, and natural orifice transluminal endoscopic surgery.

Chronic or difficult-to-treat conditions, like hepatitis and motility and functional disorders, might also assume a bigger role in practice. Nurse-practitioners and physician assistants will likely play larger roles as gastroenterologists “embrace and act on the philosophy that the gastroenterologist is the leader and manager, and not necessarily the direct provider” of digestive disease care, according to the report (Gastroenterology 2006;131:1287–312).

Dr. Timothy C. Wang, who chaired the 10-member consensus development panel, said that CTC will likely be the first technology to take a share of colorectal cancer screening, but that members found it “difficult to predict what percentage of the screening market will shift to CTC.

“Further studies will likely show that CTC is comparable to optical colonoscopy in terms of sensitivity and specificity; however, other advances also may prove to detect polyps.” Also, gastroenterologists “should not completely cede colon imaging to radiologists,” said Dr. Wang, chief of the division of digestive and liver diseases at Columbia University, New York. Some gastroenterology groups have expressed interest in purchasing CT scanners, and the committee recommended that the American Gastroenterological Association (AGA) Institute develop training programs for CTC interpretation.

Gastroenterologists contacted for their perspectives on the report called the conclusions provocative but differed about whether the report is realistic or alarmist.

The report “is thorough and thought provoking … and anything that the AGA Institute can do to raise the level of thought and discussion is laudable,” said Dr. Ronald Vender, professor of medicine at Yale University, New Haven, Conn. “I think the impact [of CTC and other changes] will be much less than they're predicting,” he said, especially when considered from a cost-benefit perspective.

“Colonoscopy rates will probably go up rather than down,” commented Dr. James T. Frakes, professor of medicine at the University of Illinois, Rockford. “But even it that's not the case, gastroenterologists should always be looking for ways to improve and broaden their services,” he said.

“Colonoscopy has become the tail that's wagged the dog,” Dr. John L. Petrini of Sansum Clinic in Santa Barbara, Calif., said. “It's become a huge part of what we do, and I'm not sure it's going to stay that way. … But I don't think that CTC is going to be the one that's a keeper.”

Optical colonoscopy also is getting better, and lesions can be removed immediately in patients who are found to have adenomatous polyps during screening. Avoiding the need for a second procedure makes optical colonoscopy a cost-effective, attractive screening option, he said.

Many patients, said Dr. Douglas K. Rex, professor of medicine at Indiana University, Indianapolis, “will be disillusioned if they have a polyp and have to go on to have another test. … Americans like effectiveness. There will be other effective devices, but it's going to be hard for them to be as effective as colonoscopy.”

There also “hasn't been adequate discussion or education of the public regarding the potential risks of radiation” associated with screening CTC, he added.

Technologies ranging from wireless capsule endoscopy to simplified endoscopes will allow generalists and even nonphysician providers to perform colon surveillance. And over the long term, it will become possible to stratify cancer risk through serum-based proteomics, for example, and genetic or epigenetic markers, eliminating “unnecessary” colonoscopies, the committee said in its report.

One major challenge in CTC interpretation, however, is the presence of significant extracolonic findings in 4.5%–12% of procedures. Direct costs would rise rapidly if all CTCs must be reviewed by radiologists for extracolonic findings after a CTC-trained gastroenterologist has reviewed the colon, the report stated.

Gastroenterologists overall may modify their scope of practice by offering services that don't require extensive retraining. Obesity care may already be too competitive a niche for gastroenterologists to claim, according to those interviewed for this article, but they largely agreed with the committee's conclusion that obesity treatment is a “natural opportunity” for gastroenterologists, especially those who are willing to be part of a multidisciplinary team.

The demand for physicians to treat functional and motility disorders is likely to increase as the population ages. New tools on the horizon should expand and improve the evaluation and management of these disorders.

The same holds true for hepatitis C therapy. “We're only at the tip of the iceberg in taking care of patients with hepatitis C and chronic liver disease,” Dr. Frakes said.

As the committee points out in its report, however, limited reimbursement for such labor-intensive cognitive services means that midlevel providers increasingly will need to be utilized to make services effective and financially viable.

In response to new technologies and expected decreases in reimbursement for “traditional” procedures, gastroenterologists “will need to change what they do, where they practice, and how they practice,” according to a report issued by the American Gastroenterological Association Institute's Future Trends Committee.

Above all, computed tomographic colonography (CTC) “is likely to become an accepted colorectal cancer screening option within 3 years,” said the report, which was based on expert presentations at a conference convened last spring.

To maintain their practices, gastroenterologists will need to consider new services, which could include providing and interpreting CTC, obesity care, gastroenterological cancer treatment, and natural orifice transluminal endoscopic surgery.

Chronic or difficult-to-treat conditions, like hepatitis and motility and functional disorders, might also assume a bigger role in practice. Nurse-practitioners and physician assistants will likely play larger roles as gastroenterologists “embrace and act on the philosophy that the gastroenterologist is the leader and manager, and not necessarily the direct provider” of digestive disease care, according to the report (Gastroenterology 2006;131:1287–312).

Dr. Timothy C. Wang, who chaired the 10-member consensus development panel, said that CTC will likely be the first technology to take a share of colorectal cancer screening, but that members found it “difficult to predict what percentage of the screening market will shift to CTC.

“Further studies will likely show that CTC is comparable to optical colonoscopy in terms of sensitivity and specificity; however, other advances also may prove to detect polyps.” Also, gastroenterologists “should not completely cede colon imaging to radiologists,” said Dr. Wang, chief of the division of digestive and liver diseases at Columbia University, New York. Some gastroenterology groups have expressed interest in purchasing CT scanners, and the committee recommended that the American Gastroenterological Association (AGA) Institute develop training programs for CTC interpretation.

Gastroenterologists contacted for their perspectives on the report called the conclusions provocative but differed about whether the report is realistic or alarmist.

The report “is thorough and thought provoking … and anything that the AGA Institute can do to raise the level of thought and discussion is laudable,” said Dr. Ronald Vender, professor of medicine at Yale University, New Haven, Conn. “I think the impact [of CTC and other changes] will be much less than they're predicting,” he said, especially when considered from a cost-benefit perspective.

“Colonoscopy rates will probably go up rather than down,” commented Dr. James T. Frakes, professor of medicine at the University of Illinois, Rockford. “But even it that's not the case, gastroenterologists should always be looking for ways to improve and broaden their services,” he said.

“Colonoscopy has become the tail that's wagged the dog,” Dr. John L. Petrini of Sansum Clinic in Santa Barbara, Calif., said. “It's become a huge part of what we do, and I'm not sure it's going to stay that way. … But I don't think that CTC is going to be the one that's a keeper.”

Optical colonoscopy also is getting better, and lesions can be removed immediately in patients who are found to have adenomatous polyps during screening. Avoiding the need for a second procedure makes optical colonoscopy a cost-effective, attractive screening option, he said.

Many patients, said Dr. Douglas K. Rex, professor of medicine at Indiana University, Indianapolis, “will be disillusioned if they have a polyp and have to go on to have another test. … Americans like effectiveness. There will be other effective devices, but it's going to be hard for them to be as effective as colonoscopy.”

There also “hasn't been adequate discussion or education of the public regarding the potential risks of radiation” associated with screening CTC, he added.

Technologies ranging from wireless capsule endoscopy to simplified endoscopes will allow generalists and even nonphysician providers to perform colon surveillance. And over the long term, it will become possible to stratify cancer risk through serum-based proteomics, for example, and genetic or epigenetic markers, eliminating “unnecessary” colonoscopies, the committee said in its report.

One major challenge in CTC interpretation, however, is the presence of significant extracolonic findings in 4.5%–12% of procedures. Direct costs would rise rapidly if all CTCs must be reviewed by radiologists for extracolonic findings after a CTC-trained gastroenterologist has reviewed the colon, the report stated.

Gastroenterologists overall may modify their scope of practice by offering services that don't require extensive retraining. Obesity care may already be too competitive a niche for gastroenterologists to claim, according to those interviewed for this article, but they largely agreed with the committee's conclusion that obesity treatment is a “natural opportunity” for gastroenterologists, especially those who are willing to be part of a multidisciplinary team.

The demand for physicians to treat functional and motility disorders is likely to increase as the population ages. New tools on the horizon should expand and improve the evaluation and management of these disorders.

The same holds true for hepatitis C therapy. “We're only at the tip of the iceberg in taking care of patients with hepatitis C and chronic liver disease,” Dr. Frakes said.

As the committee points out in its report, however, limited reimbursement for such labor-intensive cognitive services means that midlevel providers increasingly will need to be utilized to make services effective and financially viable.