Colorectal cancer is the third leading cause of cancer-related deaths in the United States, for both men and women, and across the entire population represents the second most common cause of cancer deaths and diagnoses.
According to the American Cancer Society, CRC is expected to cause approximately 52,580 deaths during 2022, with 106,180 new diagnoses of colon cancer and 44,580 new cases of rectal cancer.
The rate of patients being diagnosed with colon or rectal cancer has dropped steadily since the mid-1980s, mainly due to more people being screened. However, although the overall death rate has continued to drop, deaths from CRC among patients aged younger than 55 years have increased 1% each year from 2008 to 2017.
Recent trends indicate that gastrointestinal clinicians face new challenges when it comes to raising awareness about the importance of screening and ensuring that all patient populations receive an equitable level of screening care.
Seth A. Gross
In May 2021, the U.S. Preventive Services Task Force issued new recommendations for CRC, stating that people at average risk should start screening at age 45. Many clinical societies and recent “real world” research support this recommendation.
A retrospective study published in Cancer Epidemiology, Biomarkers & Prevention explores CRC staging. The findings show young individuals — aged 20 to 39 years — had the greatest burden of distant early-onset colorectal adenocarcinoma, likely due to being diagnosed at a later stage.
While prior studies on CRC staging combined all histologic subtypes, this analysis focused specifically on adenocarcinomas, the histologic subtype that is the focus of screening and prevention.
Surprisingly, patients aged 20 to 29 years had a 29% likelihood of presenting with distant disease compared with just 20% for those aged 50 to 54 years. Aggressive disease progression in younger patients is yet another new reality GI clinicians must confront.
Implications and Challenges
The recommended screening age for colonoscopy has been lowered by five years, which means more patients for first-time screening exams. On top of that, numerous patients put off screenings during the COVID-19 pandemic.
With a higher volume of patients to handle, GI clinicians must be more efficient in their practice while also focusing on key quality metrics and delivering accurate diagnoses. In addition to keeping pace with growing volume and a backlog of patients, GI clinicians are challenged to boost efficiency without sacrificing quality of care.
Expectations are that GI specialists will be busier than ever in 2022 and for years to come. While improving efficiency, we must also focus on delivering the highest possible quality of care. With CRC screening that means achieving a high rate of polyp detection — especially those known to be precancerous — and catching cancers as early as possible.
Process and Technology at NYU Langone
Over the past two decades, colonoscopy has undergone an evolution that is driving better detection rates as well as an improved patient experience.
One of the biggest steps forward in improving the screening procedure was the standardization of the 6-minute withdrawal. That protocol was put into place based on a 2006 study in The New England Journal of Medicine, which found the 6-minute or more withdrawal time increased polyp detection rate by 133% for all polyp sizes, especially small and medium. At NYU Langone, our gastroenterology team is very mindful of the practice, and it is making a positive difference for patients.
The GI specialty has also seen improvements, such as better maneuverability, in the instruments we utilize. Moreover, the advent of high-definition technology was a true game-changer for colonoscopy.
We have come a long way in boosting patient comfort as well, thanks in large part to the CO2 insufflation method. This method has replaced the use of air, which was prevalent early in my career. Often patients would experience abdominal bloating following the procedure, but today that problem has virtually disappeared.
Perhaps the biggest factor in the colonoscopy evolution is the recent tremendous push from physicians and industry partners to find ways to improve our ability to detect precancerous adenomas and sessile serrated lesions. Based on years of research evaluating the effectiveness of screening colonoscopy, we have been able to focus efforts and technologies on catching polyps that are most likely to progress.
Today, there are two key technology categories making colonoscopy a more effective procedure and helping clinicians be more efficient in their practice.
The first area is optical enhancement or advanced visualization. For example, a special observation mode called linked color imaging is designed to enhance mucosal visualization to aid in the detection of lesions and enable more accurate delineation. This technology can be valuable during polyp removal, especially large ones, which may need to be removed in pieces. Advanced visualization technology also can help ensure we achieve complete resection and do not leave behind any portion of a precancerous polyp. This is critically important as incomplete polyp removal puts an individual at risk for interval colon cancer.
Mechanical device enhancement is the second area of technology aimed at improving visualization in colonoscopy. A challenge with standard forward-viewing colonoscopy is that folds in the colon can make it difficult to examine the full surface area, potentially resulting in missed polyps. An early technology aimed at addressing this challenge was called full spectrum endoscopy, which expanded the endoscopic field of view to 330 degrees to enable a more complete view of the colonic surface. Another way to increase exposure of the surface area is to use devices that engage the colon throughout the exam to flatten the folds of the colonic surface. The more surface area we can see, the more likely we are to catch precancerous polyps.
At NYU Langone we evaluated G-EYE 700 Series Colonoscopes (Fujifilm), which assist with visualization, stabilization and control during the procedure. The G-EYE models include an integrated inflatable balloon that flattens surface topography of the colon and centralizes optics within the lumen.
Employing new technology like this can also make the physician’s job easier. In addition to exposing more of the colon’s surface area, the balloon assists in stabilizing the colonoscope if treatment becomes necessary. It is a powerful example of how today’s technology is helping clinicians deliver the highest quality in colonoscopy exams.
A Promising Future
The colonoscope is a powerful tool in the fight against cancer that has continued to evolve over decades. Today, we have the ability to perform colonoscopy exams that are safe and comfortable for patients, while also employing technology that delivers crisp, improved visualization and high-definition imaging. We have mechanical enhancements, like the G-EYE balloon, that expose more surface area and eliminate blind spots. We also observe an emerging role for artificial intelligence in daily clinical practice.
With robust technology on our side, GI clinicians are empowered to address the unique CRC screening challenges we currently face, which include increased patient volume. Innovations that allow us to be more efficient only support our ongoing commitment to achieve a high rate of polyp detection, meet key quality metrics and provide equitable care for all patient populations.
The future of CRC screening holds great promise, and technology will remain key. There is a possible synergy between mechanical device enhancement, high-definition imaging and the untapped potential of artificial intelligence to further improve the colonoscopy procedure. If this trio of technologies takes hold, we can expect more than just another evolutionary step for colonoscopy. We can expect something truly revolutionary.
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Seth A. Gross, MD, is the clinical chief in the division of gastroenterology and hepatology at NYU Langone Health.