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

Published:March 08, 2022DOI:

      Background and Aims

      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 >5 mm) 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 CSSDRs of 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.

      Graphical abstract


      ADR (adenoma detection rate), CRC (colorectal cancer), CSSDR (clinically significant serrated polyp detection rate), CSSP (clinically significant serrated polyp), HP (hyperplastic polyp), HR (hazard ratio), NHCR (New Hampshire Colonoscopy Registry), PCCRC (postcolonoscopy colorectal cancer), SSP (sessile serrated polyp), TSA (traditional serrated adenomas)
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        • Corley D.A.
        • Jensen C.D.
        • Marks A.R.
        • et al.
        Adenoma detection rate and risk of colorectal cancer and death.
        N Engl J Med. 2014; 370: 1298-1306
        • Kaminski M.F.
        • Regula J.
        • Kraszewska E.
        • et al.
        Quality indicators for colonoscopy and the risk of interval cancer.
        N Engl J Med. 2010; 362: 1795-1803
        • Bronzwaer M.E.S.
        • Greuter J.J.E.
        • Bliejenberg A.G.C.
        • et al.
        Impact of differences in adenoma and proximal serrated polyp detection rate on the long-term effectiveness of FIT-based colorectal cancer screening.
        BMC Cancer. 2018; 18: 465
        • Rex D.K.
        • Bond J.H.
        • Winawer S.
        • et al.
        Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer.
        Am J Gastroenterol. 2002; 97: 1296-1308
        • Rex D.K.
        • Petrini J.L.
        • Baron T.H.
        • et al.
        Quality indicators for colonoscopy.
        Gastrointest Endosc. 2006; 63: S16-S28
        • Anderson J.C.
        • Srivastava A.
        Colorectal cancer screening for the serrated pathway.
        Gastrointest Endosc Clin North Am. 2020; 30: 457-478
        • He X.
        • Hang D.
        • Wu K.
        • et al.
        Long-term risk of colorectal cancer after removal of conventional adenomas and serrated polyps.
        Gastroenterology. 2020; 158: 852-861.e4
        • Holme O.
        • Bretthauer M.
        • Eide T.J.
        • et al.
        Long-term risk of colorectal cancer in individuals with serrated polyps.
        Gut. 2015; 64: 929-936
      1. Pai RK, Mäkinen MJ, Rosty C. Colorectal serrated lesions and polyps. In: Nagtegaal ID, Arends MJ, Odze RD, Lam AK (eds). WHO Classification of Tumours of the Digestive System. Lyon: ARC Press; 2019. p. 163-169.

        • de Wijkerslooth T.R.
        • Stoop E.M.
        • Bossuyt P.M.
        • et al.
        Differences in proximal serrated polyp detection among endoscopists are associated with variability in withdrawal time.
        Gastrointest Endosc. 2013; 77: 617-623
        • IJspeert J.E.G.
        • van Doorn S.C.
        • van der Brug Y.M.
        • et al.
        The proximal serrated polyp detection rate is an easy-to-measure proxy for the detection rate of clinically relevant serrated polyps.
        Gastrointest Endosc. 2015; 82: 870-877
        • Kahi C.J.
        • Hewett D.G.
        • Norton D.L.
        • et al.
        Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy.
        Clin Gastroenterol Hepatol. 2011; 9: 42-46
        • Kahi C.J.
        • Li X.
        • Eckert G.J.
        • et al.
        High colonoscopic prevalence of proximal colon serrated polyps in average-risk men and women.
        Gastrointest Endosc. 2012; 75: 515-520
        • Payne S.R.
        • Church T.R.
        • Wandell M.
        • et al.
        Endoscopic detection of proximal serrated lesions and pathologic identification of sessile serrated adenomas/polyps vary on the basis of center.
        Clin Gastroenterol Hepatol. 2014; 12: 1119-1126
        • Anderson J.C.
        • Butterly L.F.
        • Weiss J.E.
        • et al.
        Providing data for serrated polyp detection rate benchmarks: an analysis of the New Hampshire Colonoscopy Registry.
        Gastrointest Endosc. 2017; 85: 1188-1194
        • Keswani R.N.
        • Crockett S.D.
        • Calderwood A.H.
        AGA clinical practice update on strategies to improve quality of screening and surveillance colonoscopy: expert review.
        Gastroenterology. 2021; 161: 701-711
        • Anderson J.C.
        • Lisovsky M.
        • Greene M.A.
        • et al.
        Factors associated with classification of hyperplastic polyps as sessile serrated adenomas/polyps on morphologic review.
        J Clin Gastroenterol. 2018; 52: 524-529
        • Vennelaganti S.
        • Cuatrecasas M.
        • Vennalaganti P.
        • et al.
        Interobserver agreement among pathologists in the differentiation of sessile serrated from hyperplastic polyps.
        Gastroenterology. 2021; 160: 452-454
        • Karnes W.E.
        • Johnson D.A.
        • Berzin T.M.
        • et al.
        A polyp worth removing: a paradigm for measuring colonoscopy quality and performance of novel technologies for polyp detection.
        J Clin Gastroenterol. 2021; 55: 733-739
        • Anderson J.C.
        • Robinson C.M.
        • Butterly L.F.
        Increased risk of metachronous large serrated polyps in individuals with 5- to 9-mm proximal hyperplastic polyps: data from the New Hampshire Colonoscopy Registry.
        Gastrointest Endosc. 2020; 92: 387-393
        • Greene M.A.
        • Butterly L.F.
        • Goodrich M.
        • et al.
        Matching colonoscopy and pathology data in population-based registries: development of a novel algorithm and the initial experience of the New Hampshire Colonoscopy Registry.
        Gastrointest Endosc. 2011; 74: 334-340
        • Lam A.Y.
        • Li Y.
        • Gregory D.L.
        • et al.
        Association between improved adenoma detection rates and interval colorectal cancer rates after a quality improvement program.
        Gastrointest Endosc. 2020; 92: 355-364
        • Rutter M.D.
        • Beintaris I.
        • Valori R.
        • et al.
        World Endoscopy Organization consensus statements on post-colonoscopy and post-imaging colorectal cancer.
        Gastroenterology. 2018; 155: 909-925
        • Rabeneck L.
        • Paszat L.F.
        Circumstances in which colonoscopy misses cancer.
        Frontline Gastroenterol. 2010; 1: 52-58
        • Wieszczy P.
        • Waldmann E.
        • Loberg M.
        • et al.
        Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies.
        Gastroenterology. 2021; 160: 1067-1074
        • Anderson J.C.
        • Robertson D.J.
        Serrated polyp detection by the fecal immunochemical test: an imperfect FIT.
        Clin Gastroenterol Hepatol. 2017; 15: 880-882
        • Butterly L.
        • Robinson C.M.
        • Anderson J.C.
        • et al.
        Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry.
        Am J Gastroenterol. 2014; 109: 417-426
        • Butterly L.F.
        Withdrawal time: Is nine the new six?.
        Clin Gastroenterol Hepatol. 2022; 20: e22-e24
        • Rex D.K.
        • Ahnen D.J.
        • Baron J.A.
        • et al.
        Serrated lesions of the colorectum: review and recommendations from an expert panel.
        Am J Gastroenterol. 2012; 107 (quiz 1314, 1330): 1315-1329
        • Crockett S.D.
        • Gourevitch R.A.
        • Morris M.
        • et al.
        Endoscopist factors that influence serrated polyp detection: a multicenter study.
        Endoscopy. 2018; 50: 984-992
        • Schramm C.
        • Janhsen K.
        • Hofer J.H.
        • et al.
        Detection of clinically relevant serrated polyps during screening colonoscopy: results from seven cooperating centers within the German colorectal screening program.
        Endoscopy. 2018; 50: 993-1000
        • Mandaliya R.
        • Baig K.
        • Barnhill M.
        • et al.
        Significant variation in the detection rates of proximal serrated polyps among academic gastroenterologists, community gastroenterologists, and colorectal surgeons in a single tertiary care center.
        Dig Dis Sci. 2019; 64: 2614-2621
        • Anderson J.C.
        Detection of serrated polyps: How do endoscopists rate?.
        Endoscopy. 2018; 50: 950-952
        • Desai M.
        • Anderson J.C.
        • Kaminski M.
        • et al.
        Sessile serrated lesion detection rates during average risk screening colonoscopy: a systematic review and meta-analysis of the published literature.
        Endosc Int Open. 2021; 9: E610-E620
        • Erichsen R.
        • Baron J.A.
        • Hamilton-Dutoit S.J.
        • et al.
        Increased risk of colorectal cancer development among patients with serrated polyps.
        Gastroenterology. 2016; 150: 895-902
        • Butterly L.F.
        • Nadel M.R.
        • Anderson J.C.
        • et al.
        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.
        J Clin Gastroenterol. 2020; 54: 356-364
        • Anderson J.C.
        • Butterly L.F.
        • Robinson C.M.
        • et al.
        Impact of fair bowel preparation quality on adenoma and serrated polyp detection: data from the New Hampshire Colonoscopy Registry by using a standardized preparation-quality rating.
        Gastrointest Endosc. 2014; 80: 463-470
        • Anderson R.
        • Burr N.E.
        • Valori R.
        Causes of post-colonoscopy colorectal cancers based on World Endoscopy Organization system of analysis.
        Gastroenterology. 2020; 158: 1287-1299
        • Soong T.R.
        • Nayor J.
        • Stachler M.D.
        • et al.
        Clinicopathologic and genetic characteristics of interval colorectal carcinomas favor origin from missed or incompletely excised precursors.
        Mod Pathol. 2019; 32: 666-674

      Linked Article

      • Setting a benchmark for serrated polyp detection rate: defining the target and terminology comes first
        Gastrointestinal EndoscopyVol. 96Issue 2
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          Some experts recommend the term “postcolonoscopy colorectal cancer” (PCCRC) be used to define a colorectal cancer (CRC) that occurs after a colonoscopy in which no cancer was diagnosed. PCCRC can be subtyped into “interval” cancer (diagnosed before the next recommended screening or surveillance colonoscopy) and “noninterval” cancer (identified at or after the next recommended screening or surveillance interval, or when no repeated colonoscopy was recommended, up to 10 years).1 In a review of 17 studies of nearly 150,000 cases of CRC, 5% were found to be interval PCCRCs, and these have been estimated to occur in 1 out of 3174 colonoscopies.
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