Will Pass

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

For veterans, changes in colonoscopy screening caused by the COVID-19 pandemic may have increased risks of delayed colorectal cancer (CRC) diagnosis and could lead to worse CRC outcomes, based on data from more than 33,000 patients in the Veterans Health Administration.

After COVID-19 screening policies were implemented, a significantly lower rate of veterans with red-flag signs or symptoms for CRC underwent colonoscopy, lead author Joshua Demb, PhD, a cancer epidemiologist at the University of California, San Diego, reported at the annual Digestive Disease Week® (DDW).

“As a result of the COVID-19 pandemic, the Veterans Health Administration enacted risk mitigation and management strategies in March 2020, including postponement of nearly all colonoscopies,” the investigators reported. “Notably, this included veterans with red flag signs or symptoms for CRC, among whom delays in workup could increase risk for later-stage and fatal CRC, if present.”

To measure the effects of this policy change, Dr. Demb and colleagues performed a cohort study involving 33,804 veterans with red-flag signs or symptoms for CRC, including hematochezia, iron deficiency anemia, or abnormal guaiac fecal occult blood test or fecal immunochemical test (FIT). Veterans were divided into two cohorts based on date of first red flag diagnosis: either before the COVID-19 policy was implemented (April to October 2019; n = 19,472) or after (April to October 2020; n = 14,332), with an intervening 6-month washout period.

Primary outcomes were proportion completing colonoscopy and time to colonoscopy completion. Multivariable logistic regression incorporated a number of demographic and medical covariates, including race/ethnicity, sex, age, number of red-flag signs/symptoms, first red-flag sign/symptom, and others.

Before the COVID-19 policy change, 44% of individuals with red-flag signs or symptoms received a colonoscopy, compared with 32% after the policy was introduced (P < .01). Adjusted models showed that veterans in the COVID policy group were 42% less likely to receive a diagnostic colonoscopy than those in the prepolicy group (odds ratio, 0.58; 95% confidence interval, 0.55-0.61). While these findings showed greater likelihood of receiving a screening before the pandemic, postpolicy colonoscopies were conducted sooner, with a median time to procedure of 41 days, compared with 65 days before the pandemic (P < .01). Similar differences in screening rates between pre- and postpandemic groups were observed across all types of red flag signs and symptoms.

“Lower colonoscopy uptake was observed among individuals with red-flag signs/symptoms for CRC post- versus preimplementation of COVID-19 policies, suggesting increased future risk for delayed CRC diagnosis and adverse CRC outcomes,” the investigators concluded.

Prioritization may be needed to overcome backlog of colonoscopies

Jill Tinmouth, MD, PhD, lead scientist for ColonCancerCheck, Ontario’s organized colorectal cancer screening program, and a gastroenterologist and scientist at Sunnybrook Health Sciences Centre, Toronto, shared similar concerns about delayed diagnoses.

“We might expect these cancers to present ... at a more advanced stage, and that, as a result, the outcomes from these cancers could be worse,” Dr. Tinmouth said in an interview.

She also noted the change in colonoscopy timing.

“A particularly interesting finding was that, when a colonoscopy occurred, the time to colonoscopy was shorter during the COVID era than in the pre-COVID era,” Dr. Tinmouth said. “The authors suggested that this might be as a result of Veterans Health Administration policies implemented as a result of the pandemic that led to prioritization of more urgent procedures.”

According to Dr. Tinmouth, similar prioritization may be needed to catch up with the backlog of colonoscopies created by pandemic-related policy changes. In a recent study comparing two backlog management techniques, Dr. Tinmouth and colleagues concluded that redirecting low-yield colonoscopies to FIT without increasing hospital colonoscopy capacity could reduce time to recovery by more than half.

Even so, screening programs may be facing a long road to recovery.

“Recovery of the colonoscopy backlog is going to be a challenge that will take a while – maybe even years – to resolve,” Dr. Tinmouth said. “Jurisdictions/institutions that have a strong centralized intake or triage will likely be most successful in resolving the backlog quickly as they will be able to prioritize the most urgent cases, such as persons with an abnormal FIT or with symptoms, and to redirect persons scheduled for a ‘low-yield’ colonoscopy to have a FIT instead.” Ontario defines low-yield colonoscopies as primary screening for average-risk individuals and follow-up colonoscopies for patients with low-risk adenomas at baseline.

When asked about strategies to address future pandemics, Dr. Tinmouth said, “I think that two key learnings for me from this [pandemic] are: one, not to let our guard down, and to remain vigilant and prepared – in terms of monitoring, supply chain, equipment, etc.] ... and two to create a nimble and agile health system so that we are able to assess the challenges that the next pandemic brings and address them as quickly as possible.”The investigators and Dr. Tinmouth reported no conflicts of interest.

Adversity in early life – whether preterm birth or socioeconomic disadvantage in childhood – accelerates aging, according to two recent studies, but underlying mechanisms remain unclear, and methods of investigation continue to evolve.

While one study used an established epigenetic clock to measure biological age among adults with extremely low birth weight, the other showcased a relatively new tool to measure pace of biological aging in disadvantaged children, suggesting that the metric may one day serve as a real-time measure of interventional efficacy.

These findings build upon previous studies that have demonstrated a correlation between biological age, also known as methylation age, and an increased risk of health problems later in life, according to Daniel A. Notterman, MD, professor of molecular biology at Princeton (N.J.) University.

“Finding that a person’s methylation age is greater than their chronological age has been taken as evidence of increased ‘biological age’ and perhaps a tendency to greater future morbidity,” Dr. Notterman wrote in a Pediatrics editorial. “Indeed, methylation age is advanced in association with a number of childhood and midlife adversities as well as morbidities such as atherosclerosis, cancer, and obesity.”
 

Extremely low birth weight associated with faster aging in men

For some individuals, accelerated biological aging begins at birth, or even in utero, according to Ryan J. Van Lieshout, MD, PhD, Canada Research Chair in the Perinatal Programming of Mental Disorders and the Albert Einstein/Irving Zucker Chair in Neuroscience at McMaster University, Hamilton, Ont., and colleagues.

The investigators conducted a study involving 45 extremely low birth weight (ELBW) survivors and 49 individuals born at normal birth weight. All participants were drawn from a longitudinal study conducted between 1977 and 1982 that assessed advances in neonatal intensive care. Controls were recruited at 8 years of age and matched with ELBW survivors based on family socioeconomic status, sex, and age. Follow-up continued through adulthood, allowing for the present trial to compare data from ages 8, 30, and 35.

Using samples of buccal epithelial cells, the investigators measured biological age with the Horvath epigenetic clock, the most commonly used tool of its kind, which measures cytosine-5 methylation at 353 cytosine-phosphate-guanine sites. Results were adjusted for a variety of covariates, such as smoking status, body mass index, number of chronic health conditions, and others.

Between groups, ELBW survivors trended toward older biological age, compared with adults born at normal birth weight (29.0 vs. 27.9 years), a difference that was not statistically significant. Further analysis, however, showed a significant sex-based difference between groups: Male survivors of ELBW, in adulthood, were almost 5 years biologically older than men born at normal birth weight (31.4 vs. 26.9 years; P = .01).

“[W]e provide preliminary evidence of a new link between ELBW and accelerated biological aging among men,” the investigators concluded.

In an accompanying editorial, Pam Factor-Litvak, PhD, vice chair of epidemiology at Columbia University, New York, wrote, “The findings are intriguing and open many questions for further study.”

Dr. Factor-Litvak noted that it remains unclear whether differences in biological aging were present at birth.

“[D]ifferences would provide evidence that accelerated aging begins during the in utero period, perhaps because of maternal undernutrition, stress, or another exposure,” Dr. Factor-Litvak wrote. “[R]eductions in chronic stress levels, which may begin for neonates with ELBW in utero and in the first hours of life, may provide an opportunity for interventions,” she added.

According to Calvin J. Hobel, MD, professor of pediatrics at Cedars-Sinai and professor of obstetrics and gynecology at University of California, Los Angeles, who has been studying preterm birth for more than 40 years, interventions may need to begin even earlier.

Measuring the impact of socioeconomic status on biological aging, now in real-time

A second study, by Laurel Raffington, PhD, of the University of Texas at Austin, and colleagues, evaluated the relationship between socioeconomic disadvantage in childhood and pace of biological aging.

To do so, they used the DunedinPoAm DNA methylation algorithm, a relatively new tool that was developed by analyzing changes in organ system integrity over time among adults with the same chronological age.

“Whereas epigenetic clocks quantify the amount of aging that has already occurred up to the time of measurement, DunedinPoAm quantifies how fast an individual is aging,” Dr. Raffington and colleagues wrote. “In other words, whereas epigenetic clocks tell you what time it is, pace-of-aging measures tell you how fast the clock is ticking.”

The investigators measured pace of aging in 600 children and adolescents (8-18 years of age) from the Texas Twin Project, “an ongoing longitudinal study that includes the collection of salivary samples.” The final dataset included 457 participants who identified as White, 77 who identified as Latinx, and 61 who identified as both White and Latinx.

The investigators evaluated pace of aging compared with family-level and neighborhood-level socioeconomic status, and tested for confounding by tobacco exposure, BMI, and pubertal development.

This analysis revealed that children experiencing socioeconomic disadvantage were aging more quickly than their peers, in terms of both family-level and neighborhood-level inequity (both levels, r = 0.18; P = .001).

Children who identified as Latinx aged faster than did those who identified as White only or White and Latinx, “consistent with higher levels of disadvantage in this group,” the investigators wrote. “Thus, our findings are consistent with observations that racial and/or ethnic socioeconomic disparities are an important contributor to racial and/or ethnic disparities in health.”

Higher BMI, greater tobacco exposure, and more advanced pubertal development were also associated with more rapid aging. After adjustment for these covariates, however, the significant correlation between socioeconomic disadvantage and rapid aging remained, the investigators noted.

“Our results suggest that salivary DNA methylation measures of pace of aging may provide a surrogate or intermediate endpoint for understanding the health impacts of [childhood] interventions,” the investigators concluded. “Such applications may prove particularly useful for evaluating the effectiveness of health-promoting interventions in at-risk groups.”

Still, more work is needed to understand exactly how socioeconomic disadvantage is associated with accelerated aging.

“Ultimately, not only longitudinal repeated-measures studies but also natural experiment studies and randomized controlled trials of social programs are needed to establish causal effects of social disadvantage on DunedinPoAm-measured pace of aging and to establish DunedinPoAm as a mediator of the process through which childhood disadvantage leads to aging-related health conditions,” the investigators wrote.

In his editorial, Dr. Notterman emphasized this point.

“[I]t is worth remembering that associations with either methylation age or pace of aging and health or longevity may represent the effect of an exposure on both the measure and the outcome of interest rather than a causal pathway that runs from the exposure (low socioeconomic status, adversity) to health outcome (i.e., cancer, vascular disease),” he wrote.

Paul Chung, MD, professor and chair of health systems science at Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., and adjunct professor at the University of California, Los Angeles, called the findings “preliminary,” but noted that confirmation through further research could “fill in some really important gaps.

“Right now, to some degree, we’re at a little bit of an impasse,” Dr. Chung said.

Adverse childhood experiences are “associated very strongly” with mental and physical health issues, Dr. Chung said, “but we don’t know exactly why, and because of that, it’s really hard to come up with social policy solutions that aren’t anything but extremely sort of blunt-ended. We just say, ‘Well, I guess you gotta fix everything.’ And it’s a hard place to be, I think, in the field.”

Although the present study doesn’t resolve this issue, Dr. Chung suggested that the findings “really open the door to a lot of really exciting research that could have a lot of impacts on practice and policy.”

“Sometimes the only way to get people to pay attention enough to generate the level of excitement that would allow you to even do these sorts of studies ... is to generate some initial exploratory data that makes people perk up their ears, and makes people go, ‘Hey, wow, maybe we should be looking into this.’ ”

The study by Dr. Raffington and colleagues was funded by the National Institutes of Health and the Jacobs Foundation, with additional support from the German Research Foundation, Russell Sage Foundation Biology and Social Science Grant, the Canadian Institute for Advanced Research Child and Brain Development Network, and others. The study by Dr. Lieshout and colleagues was supported by Canadian Institutes of Health Research. Dr. Factor-Litvak and Dr. Notterman reported funding from the National Institutes of Health. All of the investigators and interviewees reported no conflicts of interest.

Adversity in early life – whether preterm birth or socioeconomic disadvantage in childhood – accelerates aging, according to two recent studies, but underlying mechanisms remain unclear, and methods of investigation continue to evolve.

While one study used an established epigenetic clock to measure biological age among adults with extremely low birth weight, the other showcased a relatively new tool to measure pace of biological aging in disadvantaged children, suggesting that the metric may one day serve as a real-time measure of interventional efficacy.

These findings build upon previous studies that have demonstrated a correlation between biological age, also known as methylation age, and an increased risk of health problems later in life, according to Daniel A. Notterman, MD, professor of molecular biology at Princeton (N.J.) University.

“Finding that a person’s methylation age is greater than their chronological age has been taken as evidence of increased ‘biological age’ and perhaps a tendency to greater future morbidity,” Dr. Notterman wrote in a Pediatrics editorial. “Indeed, methylation age is advanced in association with a number of childhood and midlife adversities as well as morbidities such as atherosclerosis, cancer, and obesity.”
 

Extremely low birth weight associated with faster aging in men

For some individuals, accelerated biological aging begins at birth, or even in utero, according to Ryan J. Van Lieshout, MD, PhD, Canada Research Chair in the Perinatal Programming of Mental Disorders and the Albert Einstein/Irving Zucker Chair in Neuroscience at McMaster University, Hamilton, Ont., and colleagues.

The investigators conducted a study involving 45 extremely low birth weight (ELBW) survivors and 49 individuals born at normal birth weight. All participants were drawn from a longitudinal study conducted between 1977 and 1982 that assessed advances in neonatal intensive care. Controls were recruited at 8 years of age and matched with ELBW survivors based on family socioeconomic status, sex, and age. Follow-up continued through adulthood, allowing for the present trial to compare data from ages 8, 30, and 35.

Using samples of buccal epithelial cells, the investigators measured biological age with the Horvath epigenetic clock, the most commonly used tool of its kind, which measures cytosine-5 methylation at 353 cytosine-phosphate-guanine sites. Results were adjusted for a variety of covariates, such as smoking status, body mass index, number of chronic health conditions, and others.

Between groups, ELBW survivors trended toward older biological age, compared with adults born at normal birth weight (29.0 vs. 27.9 years), a difference that was not statistically significant. Further analysis, however, showed a significant sex-based difference between groups: Male survivors of ELBW, in adulthood, were almost 5 years biologically older than men born at normal birth weight (31.4 vs. 26.9 years; P = .01).

“[W]e provide preliminary evidence of a new link between ELBW and accelerated biological aging among men,” the investigators concluded.

In an accompanying editorial, Pam Factor-Litvak, PhD, vice chair of epidemiology at Columbia University, New York, wrote, “The findings are intriguing and open many questions for further study.”

Dr. Factor-Litvak noted that it remains unclear whether differences in biological aging were present at birth.

“[D]ifferences would provide evidence that accelerated aging begins during the in utero period, perhaps because of maternal undernutrition, stress, or another exposure,” Dr. Factor-Litvak wrote. “[R]eductions in chronic stress levels, which may begin for neonates with ELBW in utero and in the first hours of life, may provide an opportunity for interventions,” she added.

According to Calvin J. Hobel, MD, professor of pediatrics at Cedars-Sinai and professor of obstetrics and gynecology at University of California, Los Angeles, who has been studying preterm birth for more than 40 years, interventions may need to begin even earlier.

Measuring the impact of socioeconomic status on biological aging, now in real-time

A second study, by Laurel Raffington, PhD, of the University of Texas at Austin, and colleagues, evaluated the relationship between socioeconomic disadvantage in childhood and pace of biological aging.

To do so, they used the DunedinPoAm DNA methylation algorithm, a relatively new tool that was developed by analyzing changes in organ system integrity over time among adults with the same chronological age.

“Whereas epigenetic clocks quantify the amount of aging that has already occurred up to the time of measurement, DunedinPoAm quantifies how fast an individual is aging,” Dr. Raffington and colleagues wrote. “In other words, whereas epigenetic clocks tell you what time it is, pace-of-aging measures tell you how fast the clock is ticking.”

The investigators measured pace of aging in 600 children and adolescents (8-18 years of age) from the Texas Twin Project, “an ongoing longitudinal study that includes the collection of salivary samples.” The final dataset included 457 participants who identified as White, 77 who identified as Latinx, and 61 who identified as both White and Latinx.

The investigators evaluated pace of aging compared with family-level and neighborhood-level socioeconomic status, and tested for confounding by tobacco exposure, BMI, and pubertal development.

This analysis revealed that children experiencing socioeconomic disadvantage were aging more quickly than their peers, in terms of both family-level and neighborhood-level inequity (both levels, r = 0.18; P = .001).

Children who identified as Latinx aged faster than did those who identified as White only or White and Latinx, “consistent with higher levels of disadvantage in this group,” the investigators wrote. “Thus, our findings are consistent with observations that racial and/or ethnic socioeconomic disparities are an important contributor to racial and/or ethnic disparities in health.”

Higher BMI, greater tobacco exposure, and more advanced pubertal development were also associated with more rapid aging. After adjustment for these covariates, however, the significant correlation between socioeconomic disadvantage and rapid aging remained, the investigators noted.

“Our results suggest that salivary DNA methylation measures of pace of aging may provide a surrogate or intermediate endpoint for understanding the health impacts of [childhood] interventions,” the investigators concluded. “Such applications may prove particularly useful for evaluating the effectiveness of health-promoting interventions in at-risk groups.”

Still, more work is needed to understand exactly how socioeconomic disadvantage is associated with accelerated aging.

“Ultimately, not only longitudinal repeated-measures studies but also natural experiment studies and randomized controlled trials of social programs are needed to establish causal effects of social disadvantage on DunedinPoAm-measured pace of aging and to establish DunedinPoAm as a mediator of the process through which childhood disadvantage leads to aging-related health conditions,” the investigators wrote.

In his editorial, Dr. Notterman emphasized this point.

“[I]t is worth remembering that associations with either methylation age or pace of aging and health or longevity may represent the effect of an exposure on both the measure and the outcome of interest rather than a causal pathway that runs from the exposure (low socioeconomic status, adversity) to health outcome (i.e., cancer, vascular disease),” he wrote.

Paul Chung, MD, professor and chair of health systems science at Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., and adjunct professor at the University of California, Los Angeles, called the findings “preliminary,” but noted that confirmation through further research could “fill in some really important gaps.

“Right now, to some degree, we’re at a little bit of an impasse,” Dr. Chung said.

Adverse childhood experiences are “associated very strongly” with mental and physical health issues, Dr. Chung said, “but we don’t know exactly why, and because of that, it’s really hard to come up with social policy solutions that aren’t anything but extremely sort of blunt-ended. We just say, ‘Well, I guess you gotta fix everything.’ And it’s a hard place to be, I think, in the field.”

Although the present study doesn’t resolve this issue, Dr. Chung suggested that the findings “really open the door to a lot of really exciting research that could have a lot of impacts on practice and policy.”

“Sometimes the only way to get people to pay attention enough to generate the level of excitement that would allow you to even do these sorts of studies ... is to generate some initial exploratory data that makes people perk up their ears, and makes people go, ‘Hey, wow, maybe we should be looking into this.’ ”

The study by Dr. Raffington and colleagues was funded by the National Institutes of Health and the Jacobs Foundation, with additional support from the German Research Foundation, Russell Sage Foundation Biology and Social Science Grant, the Canadian Institute for Advanced Research Child and Brain Development Network, and others. The study by Dr. Lieshout and colleagues was supported by Canadian Institutes of Health Research. Dr. Factor-Litvak and Dr. Notterman reported funding from the National Institutes of Health. All of the investigators and interviewees reported no conflicts of interest.

Adversity in early life – whether preterm birth or socioeconomic disadvantage in childhood – accelerates aging, according to two recent studies, but underlying mechanisms remain unclear, and methods of investigation continue to evolve.

While one study used an established epigenetic clock to measure biological age among adults with extremely low birth weight, the other showcased a relatively new tool to measure pace of biological aging in disadvantaged children, suggesting that the metric may one day serve as a real-time measure of interventional efficacy.

These findings build upon previous studies that have demonstrated a correlation between biological age, also known as methylation age, and an increased risk of health problems later in life, according to Daniel A. Notterman, MD, professor of molecular biology at Princeton (N.J.) University.

“Finding that a person’s methylation age is greater than their chronological age has been taken as evidence of increased ‘biological age’ and perhaps a tendency to greater future morbidity,” Dr. Notterman wrote in a Pediatrics editorial. “Indeed, methylation age is advanced in association with a number of childhood and midlife adversities as well as morbidities such as atherosclerosis, cancer, and obesity.”
 

Extremely low birth weight associated with faster aging in men

For some individuals, accelerated biological aging begins at birth, or even in utero, according to Ryan J. Van Lieshout, MD, PhD, Canada Research Chair in the Perinatal Programming of Mental Disorders and the Albert Einstein/Irving Zucker Chair in Neuroscience at McMaster University, Hamilton, Ont., and colleagues.

The investigators conducted a study involving 45 extremely low birth weight (ELBW) survivors and 49 individuals born at normal birth weight. All participants were drawn from a longitudinal study conducted between 1977 and 1982 that assessed advances in neonatal intensive care. Controls were recruited at 8 years of age and matched with ELBW survivors based on family socioeconomic status, sex, and age. Follow-up continued through adulthood, allowing for the present trial to compare data from ages 8, 30, and 35.

Using samples of buccal epithelial cells, the investigators measured biological age with the Horvath epigenetic clock, the most commonly used tool of its kind, which measures cytosine-5 methylation at 353 cytosine-phosphate-guanine sites. Results were adjusted for a variety of covariates, such as smoking status, body mass index, number of chronic health conditions, and others.

Between groups, ELBW survivors trended toward older biological age, compared with adults born at normal birth weight (29.0 vs. 27.9 years), a difference that was not statistically significant. Further analysis, however, showed a significant sex-based difference between groups: Male survivors of ELBW, in adulthood, were almost 5 years biologically older than men born at normal birth weight (31.4 vs. 26.9 years; P = .01).

“[W]e provide preliminary evidence of a new link between ELBW and accelerated biological aging among men,” the investigators concluded.

In an accompanying editorial, Pam Factor-Litvak, PhD, vice chair of epidemiology at Columbia University, New York, wrote, “The findings are intriguing and open many questions for further study.”

Dr. Factor-Litvak noted that it remains unclear whether differences in biological aging were present at birth.

“[D]ifferences would provide evidence that accelerated aging begins during the in utero period, perhaps because of maternal undernutrition, stress, or another exposure,” Dr. Factor-Litvak wrote. “[R]eductions in chronic stress levels, which may begin for neonates with ELBW in utero and in the first hours of life, may provide an opportunity for interventions,” she added.

According to Calvin J. Hobel, MD, professor of pediatrics at Cedars-Sinai and professor of obstetrics and gynecology at University of California, Los Angeles, who has been studying preterm birth for more than 40 years, interventions may need to begin even earlier.

Measuring the impact of socioeconomic status on biological aging, now in real-time

A second study, by Laurel Raffington, PhD, of the University of Texas at Austin, and colleagues, evaluated the relationship between socioeconomic disadvantage in childhood and pace of biological aging.

To do so, they used the DunedinPoAm DNA methylation algorithm, a relatively new tool that was developed by analyzing changes in organ system integrity over time among adults with the same chronological age.

“Whereas epigenetic clocks quantify the amount of aging that has already occurred up to the time of measurement, DunedinPoAm quantifies how fast an individual is aging,” Dr. Raffington and colleagues wrote. “In other words, whereas epigenetic clocks tell you what time it is, pace-of-aging measures tell you how fast the clock is ticking.”

The investigators measured pace of aging in 600 children and adolescents (8-18 years of age) from the Texas Twin Project, “an ongoing longitudinal study that includes the collection of salivary samples.” The final dataset included 457 participants who identified as White, 77 who identified as Latinx, and 61 who identified as both White and Latinx.

The investigators evaluated pace of aging compared with family-level and neighborhood-level socioeconomic status, and tested for confounding by tobacco exposure, BMI, and pubertal development.

This analysis revealed that children experiencing socioeconomic disadvantage were aging more quickly than their peers, in terms of both family-level and neighborhood-level inequity (both levels, r = 0.18; P = .001).

Children who identified as Latinx aged faster than did those who identified as White only or White and Latinx, “consistent with higher levels of disadvantage in this group,” the investigators wrote. “Thus, our findings are consistent with observations that racial and/or ethnic socioeconomic disparities are an important contributor to racial and/or ethnic disparities in health.”

Higher BMI, greater tobacco exposure, and more advanced pubertal development were also associated with more rapid aging. After adjustment for these covariates, however, the significant correlation between socioeconomic disadvantage and rapid aging remained, the investigators noted.

“Our results suggest that salivary DNA methylation measures of pace of aging may provide a surrogate or intermediate endpoint for understanding the health impacts of [childhood] interventions,” the investigators concluded. “Such applications may prove particularly useful for evaluating the effectiveness of health-promoting interventions in at-risk groups.”

Still, more work is needed to understand exactly how socioeconomic disadvantage is associated with accelerated aging.

“Ultimately, not only longitudinal repeated-measures studies but also natural experiment studies and randomized controlled trials of social programs are needed to establish causal effects of social disadvantage on DunedinPoAm-measured pace of aging and to establish DunedinPoAm as a mediator of the process through which childhood disadvantage leads to aging-related health conditions,” the investigators wrote.

In his editorial, Dr. Notterman emphasized this point.

“[I]t is worth remembering that associations with either methylation age or pace of aging and health or longevity may represent the effect of an exposure on both the measure and the outcome of interest rather than a causal pathway that runs from the exposure (low socioeconomic status, adversity) to health outcome (i.e., cancer, vascular disease),” he wrote.

Paul Chung, MD, professor and chair of health systems science at Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., and adjunct professor at the University of California, Los Angeles, called the findings “preliminary,” but noted that confirmation through further research could “fill in some really important gaps.

“Right now, to some degree, we’re at a little bit of an impasse,” Dr. Chung said.

Adverse childhood experiences are “associated very strongly” with mental and physical health issues, Dr. Chung said, “but we don’t know exactly why, and because of that, it’s really hard to come up with social policy solutions that aren’t anything but extremely sort of blunt-ended. We just say, ‘Well, I guess you gotta fix everything.’ And it’s a hard place to be, I think, in the field.”

Although the present study doesn’t resolve this issue, Dr. Chung suggested that the findings “really open the door to a lot of really exciting research that could have a lot of impacts on practice and policy.”

“Sometimes the only way to get people to pay attention enough to generate the level of excitement that would allow you to even do these sorts of studies ... is to generate some initial exploratory data that makes people perk up their ears, and makes people go, ‘Hey, wow, maybe we should be looking into this.’ ”

The study by Dr. Raffington and colleagues was funded by the National Institutes of Health and the Jacobs Foundation, with additional support from the German Research Foundation, Russell Sage Foundation Biology and Social Science Grant, the Canadian Institute for Advanced Research Child and Brain Development Network, and others. The study by Dr. Lieshout and colleagues was supported by Canadian Institutes of Health Research. Dr. Factor-Litvak and Dr. Notterman reported funding from the National Institutes of Health. All of the investigators and interviewees reported no conflicts of interest.

Disposable duodenoscopes have one irrefutable advantage over their reusable counterparts: They definitively solve the problem of scope-related multidrug-resistant organism (MDRO) infections. Yet they also come with trade-offs, such as increased cost and medical waste, which has triggered pushback from skeptical endoscopists. How endoscopists weigh their differing concerns will ultimately determine the uptake of these devices going forward, according to Andrew S. Ross, MD, medical director for strategic growth at Virginia Mason Medical Center, Seattle.

“What would you pay to not have to deal with the scope infection issue at all?” Dr. Ross asked during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology. “I think that x-factor is going to depend [on] who you’re talking to and how much they really believe in [duodenoscope-related infection] as an issue.”

Dr. Ross explained that some endoscopists doubt the clinical relevance of duodenoscope-related MDRO infections, possibly because of a lack of direct experience.

“There still is a prevailing sentiment among some endoscopists that duodenoscope infection is really not a problem,” Dr. Ross said. “Or [they may say,]: ‘We haven’t had that issue here in our medical center, so therefore it is not a problem.’ ”

In fact, the exact magnitude of the problem remains unknown.

“In the end, we have an unquantifiable risk to patients wherever [reusable duodenoscopes] are used,” Dr. Ross said.
 

Just how common are scope-related MDRO infections?

According to V. Raman Muthusamy, MD, AGAF, immediate former chair of the AGA Center for GI Innovation and Technology, and director of endoscopy at the University of California, Los Angeles Health System, scope-related MDRO infections are “relatively uncommon,” but they do occur.

MDRO infections are generally linked with contaminated endoscopes, but duodenoscopes are the most common culprit because they pose a unique risk.

“Traditionally, when outbreaks have occurred [with nonduodenoscopes], it has usually been due to a breach in the reprocessing protocol,” Dr. Muthusamy said in an interview. “But with duodenoscopes, we’ve found that that does not appear to be necessary, and that in many cases there are no identified breaches, and yet there are still outbreaks.”

Dr. Muthusamy, the first endoscopist to test a disposable duodenoscope in a human patient, noted that it’s challenging to definitively prove infection from a reusable scope. Citing an Executive Summary from the Food and Drug Administration, he said, “We know it’s happened 300-400 times over the past decade or so,” with infection rates peaking in 2014-2016 and steadily declining since then.

Approximately 5% of reprocessed duodenoscopes harbor pathogenic bacteria, according to Dr. Muthusamy, but the rate of infection is significantly lower.

“[The use of a contaminated duodenoscope] doesn’t mean a patient will actually get sick ... but it does mean the potential exists, obviously,” he said. “It just shows that these devices are hard to clean and a fraction of people have the potential of becoming ill. It’s our goal to improve on those numbers, and really try to eliminate the risk of this problem, as best we can.”
 

Infection isn’t the only concern

There are several potential ways to tackle the issue of scope-related infections, Dr. Ross said during his presentation, including designing devices that are easier to clean and optimizing the cleaning process; however, the only definitive solution is to eliminate cleaning altogether.

This is where disposable duodenoscopes come in.

At present, there are two such FDA-approved devices, the Ascope Duodeno from Ambu and the Exalt Model D from Boston Scientific, both of which Dr. Ross characterized as being “in their infancy.”

Studies testing the Exalt Model D suggest that performance compares favorably with reusable duodenoscopes.

“The scope works in a benchtop model, it works in a lab, and it seems to be functional in expert hands,” Dr. Ross said. “With inexperienced users, we also see that this device works, albeit with a rate of crossover that may approach up to 10%. So, a functional, disposable scope has been produced.”

Despite availability, several pain points may slow adoption, Dr. Ross said, including reluctance to use new technology, skepticism about the clinical impact of scope-related infections, environmental concerns of increased medical waste, and increased cost.

On this latter topic, Dr. Ross pointed out that the true cost of a reusable scope goes beyond the purchase or lease price to include repair costs, reprocessing costs, and, potentially, the cost of litigation from scope-related infection.

“If you have an outbreak in your medical center, you can rest assured that you will have some litigation exposure,” Dr. Ross said.
 

Fitting disposable duodenoscopes into routine practice

Currently, both FDA-approved disposable duodenoscopes are covered by outpatient pass-through reimbursement for Medicare, and in October, both will be covered on an inpatient basis, according to Dr. Ross.

“I think the big question regarding pass-through reimbursement is what happens when the codes get revalued,” he said. “How long will the additional reimbursement stay in place?”

For now, Dr. Ross suggested that endoscopists reach for disposable duodenoscopes in unique scenarios, such as weekend or night procedures, to avoid calling in a scope-reprocessing technician; or in operating room cases when the scope enters a sterile field. Disposable scopes should also be considered for patients with known MDROs, he added, and conversely, for patients who are immunocompromised or critically ill and “can least afford a scope-related infection.”

Ultimately, the role of disposable duodenoscopes may be decided by the patients themselves, Dr. Ross concluded.

“Certainly, patients know about this – they may come in and demand the use of a single-use scope in certain situations,” Dr. Ross said. “We have to remember when we’re bringing any new technology into the marketplace that while it’s important to understand the input and perspectives of multiple stakeholders, the single-most important stakeholder at the end of the day are our patients.”

Dr. Ross disclosed a relationship with Boston Scientific. Dr. Muthusamy disclosed a relationship with Boston Scientific and Medivators.

Disposable duodenoscopes have one irrefutable advantage over their reusable counterparts: They definitively solve the problem of scope-related multidrug-resistant organism (MDRO) infections. Yet they also come with trade-offs, such as increased cost and medical waste, which has triggered pushback from skeptical endoscopists. How endoscopists weigh their differing concerns will ultimately determine the uptake of these devices going forward, according to Andrew S. Ross, MD, medical director for strategic growth at Virginia Mason Medical Center, Seattle.

“What would you pay to not have to deal with the scope infection issue at all?” Dr. Ross asked during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology. “I think that x-factor is going to depend [on] who you’re talking to and how much they really believe in [duodenoscope-related infection] as an issue.”

Dr. Ross explained that some endoscopists doubt the clinical relevance of duodenoscope-related MDRO infections, possibly because of a lack of direct experience.

“There still is a prevailing sentiment among some endoscopists that duodenoscope infection is really not a problem,” Dr. Ross said. “Or [they may say,]: ‘We haven’t had that issue here in our medical center, so therefore it is not a problem.’ ”

In fact, the exact magnitude of the problem remains unknown.

“In the end, we have an unquantifiable risk to patients wherever [reusable duodenoscopes] are used,” Dr. Ross said.
 

Just how common are scope-related MDRO infections?

According to V. Raman Muthusamy, MD, AGAF, immediate former chair of the AGA Center for GI Innovation and Technology, and director of endoscopy at the University of California, Los Angeles Health System, scope-related MDRO infections are “relatively uncommon,” but they do occur.

MDRO infections are generally linked with contaminated endoscopes, but duodenoscopes are the most common culprit because they pose a unique risk.

“Traditionally, when outbreaks have occurred [with nonduodenoscopes], it has usually been due to a breach in the reprocessing protocol,” Dr. Muthusamy said in an interview. “But with duodenoscopes, we’ve found that that does not appear to be necessary, and that in many cases there are no identified breaches, and yet there are still outbreaks.”

Dr. Muthusamy, the first endoscopist to test a disposable duodenoscope in a human patient, noted that it’s challenging to definitively prove infection from a reusable scope. Citing an Executive Summary from the Food and Drug Administration, he said, “We know it’s happened 300-400 times over the past decade or so,” with infection rates peaking in 2014-2016 and steadily declining since then.

Approximately 5% of reprocessed duodenoscopes harbor pathogenic bacteria, according to Dr. Muthusamy, but the rate of infection is significantly lower.

“[The use of a contaminated duodenoscope] doesn’t mean a patient will actually get sick ... but it does mean the potential exists, obviously,” he said. “It just shows that these devices are hard to clean and a fraction of people have the potential of becoming ill. It’s our goal to improve on those numbers, and really try to eliminate the risk of this problem, as best we can.”
 

Infection isn’t the only concern

There are several potential ways to tackle the issue of scope-related infections, Dr. Ross said during his presentation, including designing devices that are easier to clean and optimizing the cleaning process; however, the only definitive solution is to eliminate cleaning altogether.

This is where disposable duodenoscopes come in.

At present, there are two such FDA-approved devices, the Ascope Duodeno from Ambu and the Exalt Model D from Boston Scientific, both of which Dr. Ross characterized as being “in their infancy.”

Studies testing the Exalt Model D suggest that performance compares favorably with reusable duodenoscopes.

“The scope works in a benchtop model, it works in a lab, and it seems to be functional in expert hands,” Dr. Ross said. “With inexperienced users, we also see that this device works, albeit with a rate of crossover that may approach up to 10%. So, a functional, disposable scope has been produced.”

Despite availability, several pain points may slow adoption, Dr. Ross said, including reluctance to use new technology, skepticism about the clinical impact of scope-related infections, environmental concerns of increased medical waste, and increased cost.

On this latter topic, Dr. Ross pointed out that the true cost of a reusable scope goes beyond the purchase or lease price to include repair costs, reprocessing costs, and, potentially, the cost of litigation from scope-related infection.

“If you have an outbreak in your medical center, you can rest assured that you will have some litigation exposure,” Dr. Ross said.
 

Fitting disposable duodenoscopes into routine practice

Currently, both FDA-approved disposable duodenoscopes are covered by outpatient pass-through reimbursement for Medicare, and in October, both will be covered on an inpatient basis, according to Dr. Ross.

“I think the big question regarding pass-through reimbursement is what happens when the codes get revalued,” he said. “How long will the additional reimbursement stay in place?”

For now, Dr. Ross suggested that endoscopists reach for disposable duodenoscopes in unique scenarios, such as weekend or night procedures, to avoid calling in a scope-reprocessing technician; or in operating room cases when the scope enters a sterile field. Disposable scopes should also be considered for patients with known MDROs, he added, and conversely, for patients who are immunocompromised or critically ill and “can least afford a scope-related infection.”

Ultimately, the role of disposable duodenoscopes may be decided by the patients themselves, Dr. Ross concluded.

“Certainly, patients know about this – they may come in and demand the use of a single-use scope in certain situations,” Dr. Ross said. “We have to remember when we’re bringing any new technology into the marketplace that while it’s important to understand the input and perspectives of multiple stakeholders, the single-most important stakeholder at the end of the day are our patients.”

Dr. Ross disclosed a relationship with Boston Scientific. Dr. Muthusamy disclosed a relationship with Boston Scientific and Medivators.

Disposable duodenoscopes have one irrefutable advantage over their reusable counterparts: They definitively solve the problem of scope-related multidrug-resistant organism (MDRO) infections. Yet they also come with trade-offs, such as increased cost and medical waste, which has triggered pushback from skeptical endoscopists. How endoscopists weigh their differing concerns will ultimately determine the uptake of these devices going forward, according to Andrew S. Ross, MD, medical director for strategic growth at Virginia Mason Medical Center, Seattle.

“What would you pay to not have to deal with the scope infection issue at all?” Dr. Ross asked during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology. “I think that x-factor is going to depend [on] who you’re talking to and how much they really believe in [duodenoscope-related infection] as an issue.”

Dr. Ross explained that some endoscopists doubt the clinical relevance of duodenoscope-related MDRO infections, possibly because of a lack of direct experience.

“There still is a prevailing sentiment among some endoscopists that duodenoscope infection is really not a problem,” Dr. Ross said. “Or [they may say,]: ‘We haven’t had that issue here in our medical center, so therefore it is not a problem.’ ”

In fact, the exact magnitude of the problem remains unknown.

“In the end, we have an unquantifiable risk to patients wherever [reusable duodenoscopes] are used,” Dr. Ross said.
 

Just how common are scope-related MDRO infections?

According to V. Raman Muthusamy, MD, AGAF, immediate former chair of the AGA Center for GI Innovation and Technology, and director of endoscopy at the University of California, Los Angeles Health System, scope-related MDRO infections are “relatively uncommon,” but they do occur.

MDRO infections are generally linked with contaminated endoscopes, but duodenoscopes are the most common culprit because they pose a unique risk.

“Traditionally, when outbreaks have occurred [with nonduodenoscopes], it has usually been due to a breach in the reprocessing protocol,” Dr. Muthusamy said in an interview. “But with duodenoscopes, we’ve found that that does not appear to be necessary, and that in many cases there are no identified breaches, and yet there are still outbreaks.”

Dr. Muthusamy, the first endoscopist to test a disposable duodenoscope in a human patient, noted that it’s challenging to definitively prove infection from a reusable scope. Citing an Executive Summary from the Food and Drug Administration, he said, “We know it’s happened 300-400 times over the past decade or so,” with infection rates peaking in 2014-2016 and steadily declining since then.

Approximately 5% of reprocessed duodenoscopes harbor pathogenic bacteria, according to Dr. Muthusamy, but the rate of infection is significantly lower.

“[The use of a contaminated duodenoscope] doesn’t mean a patient will actually get sick ... but it does mean the potential exists, obviously,” he said. “It just shows that these devices are hard to clean and a fraction of people have the potential of becoming ill. It’s our goal to improve on those numbers, and really try to eliminate the risk of this problem, as best we can.”
 

Infection isn’t the only concern

There are several potential ways to tackle the issue of scope-related infections, Dr. Ross said during his presentation, including designing devices that are easier to clean and optimizing the cleaning process; however, the only definitive solution is to eliminate cleaning altogether.

This is where disposable duodenoscopes come in.

At present, there are two such FDA-approved devices, the Ascope Duodeno from Ambu and the Exalt Model D from Boston Scientific, both of which Dr. Ross characterized as being “in their infancy.”

Studies testing the Exalt Model D suggest that performance compares favorably with reusable duodenoscopes.

“The scope works in a benchtop model, it works in a lab, and it seems to be functional in expert hands,” Dr. Ross said. “With inexperienced users, we also see that this device works, albeit with a rate of crossover that may approach up to 10%. So, a functional, disposable scope has been produced.”

Despite availability, several pain points may slow adoption, Dr. Ross said, including reluctance to use new technology, skepticism about the clinical impact of scope-related infections, environmental concerns of increased medical waste, and increased cost.

On this latter topic, Dr. Ross pointed out that the true cost of a reusable scope goes beyond the purchase or lease price to include repair costs, reprocessing costs, and, potentially, the cost of litigation from scope-related infection.

“If you have an outbreak in your medical center, you can rest assured that you will have some litigation exposure,” Dr. Ross said.
 

Fitting disposable duodenoscopes into routine practice

Currently, both FDA-approved disposable duodenoscopes are covered by outpatient pass-through reimbursement for Medicare, and in October, both will be covered on an inpatient basis, according to Dr. Ross.

“I think the big question regarding pass-through reimbursement is what happens when the codes get revalued,” he said. “How long will the additional reimbursement stay in place?”

For now, Dr. Ross suggested that endoscopists reach for disposable duodenoscopes in unique scenarios, such as weekend or night procedures, to avoid calling in a scope-reprocessing technician; or in operating room cases when the scope enters a sterile field. Disposable scopes should also be considered for patients with known MDROs, he added, and conversely, for patients who are immunocompromised or critically ill and “can least afford a scope-related infection.”

Ultimately, the role of disposable duodenoscopes may be decided by the patients themselves, Dr. Ross concluded.

“Certainly, patients know about this – they may come in and demand the use of a single-use scope in certain situations,” Dr. Ross said. “We have to remember when we’re bringing any new technology into the marketplace that while it’s important to understand the input and perspectives of multiple stakeholders, the single-most important stakeholder at the end of the day are our patients.”

Dr. Ross disclosed a relationship with Boston Scientific. Dr. Muthusamy disclosed a relationship with Boston Scientific and Medivators.

GI Genius recently became the first Food and Drug Administration–approved device to use artificial intelligence (AI) for endoscopy. Soon, similar technology may give gastroenterologists an edge before they even walk into the procedure room.

AI can provide highly accurate risk scores for patients with suspected upper GI bleeding, and make a recommendation for discharge or hospitalization, according to Dennis Shung, MD, MHS, a clinical instructor at Yale University, New Haven, Conn. And this could provide extensive benefit.

“Acute gastrointestinal bleeding is the most common gastrointestinal diagnosis requiring hospitalization. It costs around $19.2 billion per year,” Dr. Shung said, citing a study from Gastroenterology. He made these remarks during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.

Emergency department visits for upper GI bleeding increased 17% from 2006 to 2014, Dr. Shung added, suggesting a rising trend.
 

The trouble with using risk scores

A variety of conventional risk scores are presently available to help manage these patients. Generally, they use a composite outcome of hemostatic intervention, transfusion, or death to determine which patients should be hospitalized (high risk) and which patients can go home (low risk). Although these models can offer high sensitivity, they remain underutilized.

“[Clinical risk scores] are cumbersome, it’s difficult to calculate them, [and] you may not remember to do that in your busy workflow,” Dr. Shung said.

He pointed out that low implementation may also stem from poorly defined clinical responsibilities.

“[Observing] providers caring for patients with GI bleeding showed that there was a culture of not taking ownership,” he said. “Emergency department physicians thought that it was the gastroenterologists who needed to [perform risk scoring]. Gastroenterologists thought it was the ED [physicians’ responsibility].”

To overcome these pitfalls, Dr. Shung and colleagues are developing AI that automates risk analysis for upper GI bleeding by integrating the process into the clinical workflow. Like GI Genius, their strategy relies upon machine learning, which is a type of AI that can improve automatically without being explicitly programmed.

Their most recent study (Sci Rep. 2021 Apr 23;11[1]:8827) involved a machine learning model that could predict transfusion in patients admitted for acute GI bleeding. The model was developed and internally validated in a cohort of 2,524 patients, then shown to outperform conventional regression-based models when externally validated in 1,526 patients similarly admitted at large urban hospitals.
 

Google Maps for GI bleeding

“The future, as I envision it, is a Google Maps for GI bleeding,” Dr. Shung said, referring to how the popular web-mapping product analyzes real-time data, such as weather and traffic patterns, to provide the best route and an estimated time of arrival. “With the electronic health record, we have the ability to personalize care by basically using data obtained during the clinical encounter to generate risk assessment in real time.”

In other words, machine learning software reads a patient’s electronic health record, runs relevant data through an algorithm, and produces both a risk score and a clinical recommendation. In the case of suspected upper GI bleeding, the clinician is advised to either discharge for outpatient endoscopy or hospitalize for inpatient evaluation.

Because the quality and consistency of data in EHRs can vary, the most advanced form of machine learning – deep learning – is needed to make this a clinical reality. Deep learning converts simpler concepts into complex ones. In this scenario, that would mean deciding which clinical data are relevant and which are just noise. Taking this a step further, deep learning can actually “draw conclusions” from what’s missing.

“There are huge challenges in [irregular data] that need to be overcome,” Dr. Shung said in an interview. “But I see it as an opportunity. When you see things that are irregularly sampled, when you see things are missing – they mean something. They mean that a human has decided that that is not the way we should do things because this patient doesn’t need it. And I think there is a lot of value in learning how to model those things.”
 

The road to clinical implementation

With further research and validation, deep learning models for gastroenterology are likely to play a role in clinical decision-making, according to Dr. Shung. But to reach the clinic floor, developers will need to outsmart some more fundamental obstacles. “The main thing that’s really barring [AI risk modeling] from being used is the reimbursement issue,” he said, referring to uncertainty in how payers will cover associated costs.

In an interview, Sushovan Guha, MD, PhD, moderator of the virtual session and codirector of the center for interventional gastroenterology at UTHealth (iGUT) in Houston, pointed out another financial unknown: liability.

“What happens if there is an error?” he asked. “It’s done by the computers, but who is at fault?”

In addition to these challenges, some clinicians may need to be persuaded before they are willing to trust an algorithm with a patient’s life.

“We have to have community physicians convinced about the importance of using these tools to further improve their clinical practice,” Dr. Guha said. To this end, he added, “It’s time for us to accept and adapt, and make our decision-making process much more efficient.”

The investigators disclosed no relevant conflicts of interest.

GI Genius recently became the first Food and Drug Administration–approved device to use artificial intelligence (AI) for endoscopy. Soon, similar technology may give gastroenterologists an edge before they even walk into the procedure room.

AI can provide highly accurate risk scores for patients with suspected upper GI bleeding, and make a recommendation for discharge or hospitalization, according to Dennis Shung, MD, MHS, a clinical instructor at Yale University, New Haven, Conn. And this could provide extensive benefit.

“Acute gastrointestinal bleeding is the most common gastrointestinal diagnosis requiring hospitalization. It costs around $19.2 billion per year,” Dr. Shung said, citing a study from Gastroenterology. He made these remarks during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.

Emergency department visits for upper GI bleeding increased 17% from 2006 to 2014, Dr. Shung added, suggesting a rising trend.
 

The trouble with using risk scores

A variety of conventional risk scores are presently available to help manage these patients. Generally, they use a composite outcome of hemostatic intervention, transfusion, or death to determine which patients should be hospitalized (high risk) and which patients can go home (low risk). Although these models can offer high sensitivity, they remain underutilized.

“[Clinical risk scores] are cumbersome, it’s difficult to calculate them, [and] you may not remember to do that in your busy workflow,” Dr. Shung said.

He pointed out that low implementation may also stem from poorly defined clinical responsibilities.

“[Observing] providers caring for patients with GI bleeding showed that there was a culture of not taking ownership,” he said. “Emergency department physicians thought that it was the gastroenterologists who needed to [perform risk scoring]. Gastroenterologists thought it was the ED [physicians’ responsibility].”

To overcome these pitfalls, Dr. Shung and colleagues are developing AI that automates risk analysis for upper GI bleeding by integrating the process into the clinical workflow. Like GI Genius, their strategy relies upon machine learning, which is a type of AI that can improve automatically without being explicitly programmed.

Their most recent study (Sci Rep. 2021 Apr 23;11[1]:8827) involved a machine learning model that could predict transfusion in patients admitted for acute GI bleeding. The model was developed and internally validated in a cohort of 2,524 patients, then shown to outperform conventional regression-based models when externally validated in 1,526 patients similarly admitted at large urban hospitals.
 

Google Maps for GI bleeding

“The future, as I envision it, is a Google Maps for GI bleeding,” Dr. Shung said, referring to how the popular web-mapping product analyzes real-time data, such as weather and traffic patterns, to provide the best route and an estimated time of arrival. “With the electronic health record, we have the ability to personalize care by basically using data obtained during the clinical encounter to generate risk assessment in real time.”

In other words, machine learning software reads a patient’s electronic health record, runs relevant data through an algorithm, and produces both a risk score and a clinical recommendation. In the case of suspected upper GI bleeding, the clinician is advised to either discharge for outpatient endoscopy or hospitalize for inpatient evaluation.

Because the quality and consistency of data in EHRs can vary, the most advanced form of machine learning – deep learning – is needed to make this a clinical reality. Deep learning converts simpler concepts into complex ones. In this scenario, that would mean deciding which clinical data are relevant and which are just noise. Taking this a step further, deep learning can actually “draw conclusions” from what’s missing.

“There are huge challenges in [irregular data] that need to be overcome,” Dr. Shung said in an interview. “But I see it as an opportunity. When you see things that are irregularly sampled, when you see things are missing – they mean something. They mean that a human has decided that that is not the way we should do things because this patient doesn’t need it. And I think there is a lot of value in learning how to model those things.”
 

The road to clinical implementation

With further research and validation, deep learning models for gastroenterology are likely to play a role in clinical decision-making, according to Dr. Shung. But to reach the clinic floor, developers will need to outsmart some more fundamental obstacles. “The main thing that’s really barring [AI risk modeling] from being used is the reimbursement issue,” he said, referring to uncertainty in how payers will cover associated costs.

In an interview, Sushovan Guha, MD, PhD, moderator of the virtual session and codirector of the center for interventional gastroenterology at UTHealth (iGUT) in Houston, pointed out another financial unknown: liability.

“What happens if there is an error?” he asked. “It’s done by the computers, but who is at fault?”

In addition to these challenges, some clinicians may need to be persuaded before they are willing to trust an algorithm with a patient’s life.

“We have to have community physicians convinced about the importance of using these tools to further improve their clinical practice,” Dr. Guha said. To this end, he added, “It’s time for us to accept and adapt, and make our decision-making process much more efficient.”

The investigators disclosed no relevant conflicts of interest.

GI Genius recently became the first Food and Drug Administration–approved device to use artificial intelligence (AI) for endoscopy. Soon, similar technology may give gastroenterologists an edge before they even walk into the procedure room.

AI can provide highly accurate risk scores for patients with suspected upper GI bleeding, and make a recommendation for discharge or hospitalization, according to Dennis Shung, MD, MHS, a clinical instructor at Yale University, New Haven, Conn. And this could provide extensive benefit.

“Acute gastrointestinal bleeding is the most common gastrointestinal diagnosis requiring hospitalization. It costs around $19.2 billion per year,” Dr. Shung said, citing a study from Gastroenterology. He made these remarks during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.

Emergency department visits for upper GI bleeding increased 17% from 2006 to 2014, Dr. Shung added, suggesting a rising trend.
 

The trouble with using risk scores

A variety of conventional risk scores are presently available to help manage these patients. Generally, they use a composite outcome of hemostatic intervention, transfusion, or death to determine which patients should be hospitalized (high risk) and which patients can go home (low risk). Although these models can offer high sensitivity, they remain underutilized.

“[Clinical risk scores] are cumbersome, it’s difficult to calculate them, [and] you may not remember to do that in your busy workflow,” Dr. Shung said.

He pointed out that low implementation may also stem from poorly defined clinical responsibilities.

“[Observing] providers caring for patients with GI bleeding showed that there was a culture of not taking ownership,” he said. “Emergency department physicians thought that it was the gastroenterologists who needed to [perform risk scoring]. Gastroenterologists thought it was the ED [physicians’ responsibility].”

To overcome these pitfalls, Dr. Shung and colleagues are developing AI that automates risk analysis for upper GI bleeding by integrating the process into the clinical workflow. Like GI Genius, their strategy relies upon machine learning, which is a type of AI that can improve automatically without being explicitly programmed.

Their most recent study (Sci Rep. 2021 Apr 23;11[1]:8827) involved a machine learning model that could predict transfusion in patients admitted for acute GI bleeding. The model was developed and internally validated in a cohort of 2,524 patients, then shown to outperform conventional regression-based models when externally validated in 1,526 patients similarly admitted at large urban hospitals.
 

Google Maps for GI bleeding

“The future, as I envision it, is a Google Maps for GI bleeding,” Dr. Shung said, referring to how the popular web-mapping product analyzes real-time data, such as weather and traffic patterns, to provide the best route and an estimated time of arrival. “With the electronic health record, we have the ability to personalize care by basically using data obtained during the clinical encounter to generate risk assessment in real time.”

In other words, machine learning software reads a patient’s electronic health record, runs relevant data through an algorithm, and produces both a risk score and a clinical recommendation. In the case of suspected upper GI bleeding, the clinician is advised to either discharge for outpatient endoscopy or hospitalize for inpatient evaluation.

Because the quality and consistency of data in EHRs can vary, the most advanced form of machine learning – deep learning – is needed to make this a clinical reality. Deep learning converts simpler concepts into complex ones. In this scenario, that would mean deciding which clinical data are relevant and which are just noise. Taking this a step further, deep learning can actually “draw conclusions” from what’s missing.

“There are huge challenges in [irregular data] that need to be overcome,” Dr. Shung said in an interview. “But I see it as an opportunity. When you see things that are irregularly sampled, when you see things are missing – they mean something. They mean that a human has decided that that is not the way we should do things because this patient doesn’t need it. And I think there is a lot of value in learning how to model those things.”
 

The road to clinical implementation

With further research and validation, deep learning models for gastroenterology are likely to play a role in clinical decision-making, according to Dr. Shung. But to reach the clinic floor, developers will need to outsmart some more fundamental obstacles. “The main thing that’s really barring [AI risk modeling] from being used is the reimbursement issue,” he said, referring to uncertainty in how payers will cover associated costs.

In an interview, Sushovan Guha, MD, PhD, moderator of the virtual session and codirector of the center for interventional gastroenterology at UTHealth (iGUT) in Houston, pointed out another financial unknown: liability.

“What happens if there is an error?” he asked. “It’s done by the computers, but who is at fault?”

In addition to these challenges, some clinicians may need to be persuaded before they are willing to trust an algorithm with a patient’s life.

“We have to have community physicians convinced about the importance of using these tools to further improve their clinical practice,” Dr. Guha said. To this end, he added, “It’s time for us to accept and adapt, and make our decision-making process much more efficient.”

The investigators disclosed no relevant conflicts of interest.

William of Ockham would have been proud because, at this year’s American Gastroenterological Association’s Shark Tank pitch competition, one product clearly demonstrated Ockham’s razor – that sometimes the simplest solution is best – and came away as the winner at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.

Courtesy Dr. Toufic Kachaamy

Out of five innovative products, ranging from an educational app to a high-tech anorectal sensor, all aimed at improving outcomes in patients with gastrointestinal disorders, the winner was ... drumroll please ...

A needle.

That’s it. A needle. But not like any other needle.


 

Winner: Toufic Kachaamy, MD, FASGE, AGAF – An EUS-guided access needle

This EUS-guided access needle, invented by Dr. Kachaamy, enterprise clinical leader at Cancer Treatment Centers of America, Phoenix, is a simple device that overcomes a longstanding challenge presented by endoscopic retrograde cholangiopancreatography (ERCP): biliary access.

Many “ERCPs are considered difficult, and sometimes fail, depending on the center and the endoscopist,” Dr. Kachaamy said during a virtual presentation. “Most failures are due to failed initial access to the bile duct.”

Indeed, one study cited a failure rate in ductal cannulation of 5%-15% even among experienced hands.

Failure can have several consequences, Dr. Kachaamy noted, including increased complications, higher cost, delayed care, longer hospitalization, and greater likelihood of patient transfer.

He went on to explain why biliary access can be so challenging and how this EUS-guided access needle helps address these issues.

“[The] two main limitations [during endoscopic ultrasound–guided biliary access] are directing the wire into the narrowed areas and the wire shearing as we are manipulating the wire to get it to where we want it,” Dr. Kachaamy said. “[This EUS-guided access needle] is a 19-22 gauge, rotatable needle with a smooth, side exit for the wire to allow wire manipulation and direction without shearing.”

Dr. Kachaamy highlighted the simple design, which will keep the production cost below $300 per unit, and suggested that failed ERCPs are just the first potential indication of many. Future uses may include gallbladder access, peri-GI collection, gastrojejunostomy, and others.

In an interview, Dr. Kachaamy reacted to the win, which follows 2 years of collaborative development with Cancer Treatment Centers of America.

“For people who are innovators, there’s nothing that feels more rewarding than their ideas being recognized as adding something to the field and potentially helping people and patients,” Dr. Kachaamy said. “So [this is] very, very, very exciting. Very rewarding. Pride would probably be the best way I’d describe it.”

Dr. Kachaamy anticipates that this EUS-guided access needle will be commercially available within 1-2 years, pending regulatory approval. In the meantime, he and his colleagues are seeking a strategic partner.


 

A shark speaks

V. Raman Muthusamy, MD, AGAF, immediate past chair of the AGA Center for GI Innovation and Technology and director of endoscopy at UCLA Health System, moderated the Shark Tank session, calling it “the highlight” of the AGA Tech Summit.

Dr. Muthusamy and four other “sharks,” including a gastroenterologist, venture capitalist, regulatory device reviewer, and entrepreneur, scored the pitches using three equally weighted categories: the quality of the pitch, the level of innovation and impact on the field, and the quality of the business plan and overall feasibility.

“We saw a full spectrum [of innovations],” Dr. Muthusamy said. “I think it was an enjoyable session.”

Behind closed doors, the sharks narrowed the field to two top contenders. Ultimately, however, there could be only one winner: Dr. Kachaamy. Their decision aligned with a “Fan Favorite” audience poll.

“A lot of [Dr. Kachaamy’s win] had to do with the potential applications and commonality of the problem,” Dr. Muthusamy said in an interview. He highlighted how the EUS-guided access needle allows for an immediate response to ERCP failure without the need for a second procedure.

Dr. Muthusamy also noted that several product designs previously failed to achieve what the EUS-guided access needle has the potential to do.

“I think the feeling was that this seemed to be a way that may address some of the limitations and challenges that we’ve had with earlier [attempts at solving this problem],” Dr. Muthusamy said.

For innovators who didn’t make the cut this year, or those with products still in development, Dr. Muthusamy suggested applying next year.

“We encourage our colleagues and members of the AGA to continue to apply to this program,” Dr. Muthusamy said.
 

Other fish in the sea

Four other innovators entered the AGA Shark Tank this year. Here are snippets of their pitches:

Hans Gregersen, MD, PhD, MPH – Fecobionics
“Fecobionics is a simulated electronic stool with the consistency and shape of normal stool,” Dr. Gregersen said.

The balloon device, which contains multiple sensors, provides “real-time, quantitative, and mechanistic insights by simulating defecation.”

“It ... is inserted into the rectum,” Dr. Gregersen said. “It measures multiple pressures; it has gyroscopes that measure orientation; we can compute the bending of the device; and we can calculate the shape of the device.”

According to Dr. Gregersen, Fecobionics has “diagnostic potential for patients with fecal incontinence and for subtyping patients with constipation.” He highlighted fewer false-positives than current technology, alongside greater efficiency and lower cost.

Dr. Gregersen is a research professor at California Medical Innovations Institute, San Diego.

Mary J. Pattison, RN – Trans-Abdominal Gastric Surgical System (TAGSS)
TAGSS is a trans-abdominal gastric access device that “represents a novel and exciting means to address multiple gastrointestinal conditions that are without a standardized approach,” Ms. Pattison said. “Placed as simply as a [percutaneous endoscopic gastrostomy tube], TAGSS offers disruptive technology to address [gastroesophageal reflux disease], fundoplication, achalasia, gastroparesis, gastric tumors, and even obesity in a safe, efficient, and cost effective manner. TAGSS offers the first true hybrid approach for endoscopic/laparoscopic collaboration.”

Ms. Pattison is a nurse clinician and endoscopy assistant at WestGlen GI Consultants, Weston, Mo.

Pankaj Rajvanshi, MD, FAASLD – Healthswim App
“At this time, most patient education is provided by Dr. Google,” Dr. Rajvanshi said, “and we want to change that. We have built a platform which allows you, the physician, to create custom, curated, credible content that can be delivered seamlessly to your patients on an ongoing basis.”

Through the Healthswim app, patients subscribe to their providers, allowing access physician-approved content. Subscribers also receive provider updates through their social media feeds.

Dr. Rajvanshi is a gastroenterologist at Swedish Medical Center, Seattle.

Ali S. Karakurum, MD, FACP, FACG – A Device for Removal of Esophageal Food Impactions
“I would like to propose a device which consists of a clear overtube, a collapsible plastic cylindrical basket secured to the distal end of the overtube ... and a snare wire attached to the distal end of the basket which is controlled by the snare handle externally,” Dr. Karakurum said. “The device is ... gradually advanced over the scope for the basket to encompass the food bolus under direct visualization. Once the food bolus is within the basket, the wire loop at the end of the basket is closed via the external handle, securing the food bolus in the basket for safe removal.”

Dr. Karakurum is a gastroenterologist at Advanced Gastroenterology & Endoscopy, Port Jefferson, N.Y.

This article was updated 5/14/21.

William of Ockham would have been proud because, at this year’s American Gastroenterological Association’s Shark Tank pitch competition, one product clearly demonstrated Ockham’s razor – that sometimes the simplest solution is best – and came away as the winner at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.

Courtesy Dr. Toufic Kachaamy

Out of five innovative products, ranging from an educational app to a high-tech anorectal sensor, all aimed at improving outcomes in patients with gastrointestinal disorders, the winner was ... drumroll please ...

A needle.

That’s it. A needle. But not like any other needle.


 

Winner: Toufic Kachaamy, MD, FASGE, AGAF – An EUS-guided access needle

This EUS-guided access needle, invented by Dr. Kachaamy, enterprise clinical leader at Cancer Treatment Centers of America, Phoenix, is a simple device that overcomes a longstanding challenge presented by endoscopic retrograde cholangiopancreatography (ERCP): biliary access.

Many “ERCPs are considered difficult, and sometimes fail, depending on the center and the endoscopist,” Dr. Kachaamy said during a virtual presentation. “Most failures are due to failed initial access to the bile duct.”

Indeed, one study cited a failure rate in ductal cannulation of 5%-15% even among experienced hands.

Failure can have several consequences, Dr. Kachaamy noted, including increased complications, higher cost, delayed care, longer hospitalization, and greater likelihood of patient transfer.

He went on to explain why biliary access can be so challenging and how this EUS-guided access needle helps address these issues.

“[The] two main limitations [during endoscopic ultrasound–guided biliary access] are directing the wire into the narrowed areas and the wire shearing as we are manipulating the wire to get it to where we want it,” Dr. Kachaamy said. “[This EUS-guided access needle] is a 19-22 gauge, rotatable needle with a smooth, side exit for the wire to allow wire manipulation and direction without shearing.”

Dr. Kachaamy highlighted the simple design, which will keep the production cost below $300 per unit, and suggested that failed ERCPs are just the first potential indication of many. Future uses may include gallbladder access, peri-GI collection, gastrojejunostomy, and others.

In an interview, Dr. Kachaamy reacted to the win, which follows 2 years of collaborative development with Cancer Treatment Centers of America.

“For people who are innovators, there’s nothing that feels more rewarding than their ideas being recognized as adding something to the field and potentially helping people and patients,” Dr. Kachaamy said. “So [this is] very, very, very exciting. Very rewarding. Pride would probably be the best way I’d describe it.”

Dr. Kachaamy anticipates that this EUS-guided access needle will be commercially available within 1-2 years, pending regulatory approval. In the meantime, he and his colleagues are seeking a strategic partner.


 

A shark speaks

V. Raman Muthusamy, MD, AGAF, immediate past chair of the AGA Center for GI Innovation and Technology and director of endoscopy at UCLA Health System, moderated the Shark Tank session, calling it “the highlight” of the AGA Tech Summit.

Dr. Muthusamy and four other “sharks,” including a gastroenterologist, venture capitalist, regulatory device reviewer, and entrepreneur, scored the pitches using three equally weighted categories: the quality of the pitch, the level of innovation and impact on the field, and the quality of the business plan and overall feasibility.

“We saw a full spectrum [of innovations],” Dr. Muthusamy said. “I think it was an enjoyable session.”

Behind closed doors, the sharks narrowed the field to two top contenders. Ultimately, however, there could be only one winner: Dr. Kachaamy. Their decision aligned with a “Fan Favorite” audience poll.

“A lot of [Dr. Kachaamy’s win] had to do with the potential applications and commonality of the problem,” Dr. Muthusamy said in an interview. He highlighted how the EUS-guided access needle allows for an immediate response to ERCP failure without the need for a second procedure.

Dr. Muthusamy also noted that several product designs previously failed to achieve what the EUS-guided access needle has the potential to do.

“I think the feeling was that this seemed to be a way that may address some of the limitations and challenges that we’ve had with earlier [attempts at solving this problem],” Dr. Muthusamy said.

For innovators who didn’t make the cut this year, or those with products still in development, Dr. Muthusamy suggested applying next year.

“We encourage our colleagues and members of the AGA to continue to apply to this program,” Dr. Muthusamy said.
 

Other fish in the sea

Four other innovators entered the AGA Shark Tank this year. Here are snippets of their pitches:

Hans Gregersen, MD, PhD, MPH – Fecobionics
“Fecobionics is a simulated electronic stool with the consistency and shape of normal stool,” Dr. Gregersen said.

The balloon device, which contains multiple sensors, provides “real-time, quantitative, and mechanistic insights by simulating defecation.”

“It ... is inserted into the rectum,” Dr. Gregersen said. “It measures multiple pressures; it has gyroscopes that measure orientation; we can compute the bending of the device; and we can calculate the shape of the device.”

According to Dr. Gregersen, Fecobionics has “diagnostic potential for patients with fecal incontinence and for subtyping patients with constipation.” He highlighted fewer false-positives than current technology, alongside greater efficiency and lower cost.

Dr. Gregersen is a research professor at California Medical Innovations Institute, San Diego.

Mary J. Pattison, RN – Trans-Abdominal Gastric Surgical System (TAGSS)
TAGSS is a trans-abdominal gastric access device that “represents a novel and exciting means to address multiple gastrointestinal conditions that are without a standardized approach,” Ms. Pattison said. “Placed as simply as a [percutaneous endoscopic gastrostomy tube], TAGSS offers disruptive technology to address [gastroesophageal reflux disease], fundoplication, achalasia, gastroparesis, gastric tumors, and even obesity in a safe, efficient, and cost effective manner. TAGSS offers the first true hybrid approach for endoscopic/laparoscopic collaboration.”

Ms. Pattison is a nurse clinician and endoscopy assistant at WestGlen GI Consultants, Weston, Mo.

Pankaj Rajvanshi, MD, FAASLD – Healthswim App
“At this time, most patient education is provided by Dr. Google,” Dr. Rajvanshi said, “and we want to change that. We have built a platform which allows you, the physician, to create custom, curated, credible content that can be delivered seamlessly to your patients on an ongoing basis.”

Through the Healthswim app, patients subscribe to their providers, allowing access physician-approved content. Subscribers also receive provider updates through their social media feeds.

Dr. Rajvanshi is a gastroenterologist at Swedish Medical Center, Seattle.

Ali S. Karakurum, MD, FACP, FACG – A Device for Removal of Esophageal Food Impactions
“I would like to propose a device which consists of a clear overtube, a collapsible plastic cylindrical basket secured to the distal end of the overtube ... and a snare wire attached to the distal end of the basket which is controlled by the snare handle externally,” Dr. Karakurum said. “The device is ... gradually advanced over the scope for the basket to encompass the food bolus under direct visualization. Once the food bolus is within the basket, the wire loop at the end of the basket is closed via the external handle, securing the food bolus in the basket for safe removal.”

Dr. Karakurum is a gastroenterologist at Advanced Gastroenterology & Endoscopy, Port Jefferson, N.Y.

This article was updated 5/14/21.

William of Ockham would have been proud because, at this year’s American Gastroenterological Association’s Shark Tank pitch competition, one product clearly demonstrated Ockham’s razor – that sometimes the simplest solution is best – and came away as the winner at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.

Courtesy Dr. Toufic Kachaamy

Out of five innovative products, ranging from an educational app to a high-tech anorectal sensor, all aimed at improving outcomes in patients with gastrointestinal disorders, the winner was ... drumroll please ...

A needle.

That’s it. A needle. But not like any other needle.


 

Winner: Toufic Kachaamy, MD, FASGE, AGAF – An EUS-guided access needle

This EUS-guided access needle, invented by Dr. Kachaamy, enterprise clinical leader at Cancer Treatment Centers of America, Phoenix, is a simple device that overcomes a longstanding challenge presented by endoscopic retrograde cholangiopancreatography (ERCP): biliary access.

Many “ERCPs are considered difficult, and sometimes fail, depending on the center and the endoscopist,” Dr. Kachaamy said during a virtual presentation. “Most failures are due to failed initial access to the bile duct.”

Indeed, one study cited a failure rate in ductal cannulation of 5%-15% even among experienced hands.

Failure can have several consequences, Dr. Kachaamy noted, including increased complications, higher cost, delayed care, longer hospitalization, and greater likelihood of patient transfer.

He went on to explain why biliary access can be so challenging and how this EUS-guided access needle helps address these issues.

“[The] two main limitations [during endoscopic ultrasound–guided biliary access] are directing the wire into the narrowed areas and the wire shearing as we are manipulating the wire to get it to where we want it,” Dr. Kachaamy said. “[This EUS-guided access needle] is a 19-22 gauge, rotatable needle with a smooth, side exit for the wire to allow wire manipulation and direction without shearing.”

Dr. Kachaamy highlighted the simple design, which will keep the production cost below $300 per unit, and suggested that failed ERCPs are just the first potential indication of many. Future uses may include gallbladder access, peri-GI collection, gastrojejunostomy, and others.

In an interview, Dr. Kachaamy reacted to the win, which follows 2 years of collaborative development with Cancer Treatment Centers of America.

“For people who are innovators, there’s nothing that feels more rewarding than their ideas being recognized as adding something to the field and potentially helping people and patients,” Dr. Kachaamy said. “So [this is] very, very, very exciting. Very rewarding. Pride would probably be the best way I’d describe it.”

Dr. Kachaamy anticipates that this EUS-guided access needle will be commercially available within 1-2 years, pending regulatory approval. In the meantime, he and his colleagues are seeking a strategic partner.


 

A shark speaks

V. Raman Muthusamy, MD, AGAF, immediate past chair of the AGA Center for GI Innovation and Technology and director of endoscopy at UCLA Health System, moderated the Shark Tank session, calling it “the highlight” of the AGA Tech Summit.

Dr. Muthusamy and four other “sharks,” including a gastroenterologist, venture capitalist, regulatory device reviewer, and entrepreneur, scored the pitches using three equally weighted categories: the quality of the pitch, the level of innovation and impact on the field, and the quality of the business plan and overall feasibility.

“We saw a full spectrum [of innovations],” Dr. Muthusamy said. “I think it was an enjoyable session.”

Behind closed doors, the sharks narrowed the field to two top contenders. Ultimately, however, there could be only one winner: Dr. Kachaamy. Their decision aligned with a “Fan Favorite” audience poll.

“A lot of [Dr. Kachaamy’s win] had to do with the potential applications and commonality of the problem,” Dr. Muthusamy said in an interview. He highlighted how the EUS-guided access needle allows for an immediate response to ERCP failure without the need for a second procedure.

Dr. Muthusamy also noted that several product designs previously failed to achieve what the EUS-guided access needle has the potential to do.

“I think the feeling was that this seemed to be a way that may address some of the limitations and challenges that we’ve had with earlier [attempts at solving this problem],” Dr. Muthusamy said.

For innovators who didn’t make the cut this year, or those with products still in development, Dr. Muthusamy suggested applying next year.

“We encourage our colleagues and members of the AGA to continue to apply to this program,” Dr. Muthusamy said.
 

Other fish in the sea

Four other innovators entered the AGA Shark Tank this year. Here are snippets of their pitches:

Hans Gregersen, MD, PhD, MPH – Fecobionics
“Fecobionics is a simulated electronic stool with the consistency and shape of normal stool,” Dr. Gregersen said.

The balloon device, which contains multiple sensors, provides “real-time, quantitative, and mechanistic insights by simulating defecation.”

“It ... is inserted into the rectum,” Dr. Gregersen said. “It measures multiple pressures; it has gyroscopes that measure orientation; we can compute the bending of the device; and we can calculate the shape of the device.”

According to Dr. Gregersen, Fecobionics has “diagnostic potential for patients with fecal incontinence and for subtyping patients with constipation.” He highlighted fewer false-positives than current technology, alongside greater efficiency and lower cost.

Dr. Gregersen is a research professor at California Medical Innovations Institute, San Diego.

Mary J. Pattison, RN – Trans-Abdominal Gastric Surgical System (TAGSS)
TAGSS is a trans-abdominal gastric access device that “represents a novel and exciting means to address multiple gastrointestinal conditions that are without a standardized approach,” Ms. Pattison said. “Placed as simply as a [percutaneous endoscopic gastrostomy tube], TAGSS offers disruptive technology to address [gastroesophageal reflux disease], fundoplication, achalasia, gastroparesis, gastric tumors, and even obesity in a safe, efficient, and cost effective manner. TAGSS offers the first true hybrid approach for endoscopic/laparoscopic collaboration.”

Ms. Pattison is a nurse clinician and endoscopy assistant at WestGlen GI Consultants, Weston, Mo.

Pankaj Rajvanshi, MD, FAASLD – Healthswim App
“At this time, most patient education is provided by Dr. Google,” Dr. Rajvanshi said, “and we want to change that. We have built a platform which allows you, the physician, to create custom, curated, credible content that can be delivered seamlessly to your patients on an ongoing basis.”

Through the Healthswim app, patients subscribe to their providers, allowing access physician-approved content. Subscribers also receive provider updates through their social media feeds.

Dr. Rajvanshi is a gastroenterologist at Swedish Medical Center, Seattle.

Ali S. Karakurum, MD, FACP, FACG – A Device for Removal of Esophageal Food Impactions
“I would like to propose a device which consists of a clear overtube, a collapsible plastic cylindrical basket secured to the distal end of the overtube ... and a snare wire attached to the distal end of the basket which is controlled by the snare handle externally,” Dr. Karakurum said. “The device is ... gradually advanced over the scope for the basket to encompass the food bolus under direct visualization. Once the food bolus is within the basket, the wire loop at the end of the basket is closed via the external handle, securing the food bolus in the basket for safe removal.”

Dr. Karakurum is a gastroenterologist at Advanced Gastroenterology & Endoscopy, Port Jefferson, N.Y.

This article was updated 5/14/21.

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

Endoscopists are at high risk of musculoskeletal issues, and a multifaceted strategy is needed to reduce rates of injury, including better body posture and endoscopic suite layout, according to leading experts.

Andrey Shevchuk/iStock/Getty Images

Latha Alaparthi, MD, director of committee operations at Gastroenterology Center of Connecticut, Hamden, and assistant clinical professor at Yale University, New Haven, Conn., noted that female gastroenterologists are at particular risk because they often work with outsize equipment and suboptimal room setup.

“I think it’s something for us to recognize, and [we need to] find ways to protect ourselves,” Dr. Alaparthi said during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.
 

Prevalence of musculoskeletal injuries in gastroenterology

Gastroenterologists spend 43% of their time performing procedures, Dr. Alaparthi said, and all those hours take a toll on the body. Up to 89% of gastroenterologists report musculoskeletal symptoms – most often back pain, followed by neck pain and hand pain.

Even newcomers to the field are at risk, she added, noting that 47% of gastroenterology fellows report injury in their first year of training. And with one out of three fellows now female, the issue may be a growing concern.

“As female gastroenterologists, we are even more at risk,” Dr. Alaparthi said. This is partly due to differences in equipment and room design, which “take into consideration 5% of female average measurements and 95% of that of males.”

The resultant injuries may be enough to drive female doctors from the field. Dr. Alaparthi recounted her colleague’s experience in leaving gastroenterology for the pharmaceutical industry after experiencing ongoing neck pain.

“She called me and said 1 week after she stopped doing endoscopies, her neck pain was gone.”

For gastroenterologists of any gender, musculoskeletal injuries can cause pain and suffering, reduced quality of life, lost or reduced work output, short-term or permanent disability, lost wages, and impediment to career advancement. Yet physicians aren’t the only stakeholders affected by these injuries. Employers stand to lose financially from decreased productivity and increased compensation costs.

“[Injuries have] implications not just to the individual but to the company and to patient care,” Dr. Alaparthi said.

She went on to suggest that an effective solution to the problem will require efforts from both gastroenterologists and institutions, including greater self-awareness of body positioning, access to anthropometrically suitable equipment, better room design, and a work culture that supports breaks during procedures, if needed.

“We definitely need programs to provide comprehensive work force injury prevention and protection specific to GI endoscopy – not just for gastroenterologists, but for the whole team involved.”

Ergonomics in endoscopy training

Presenting after Dr. Alaparthi, Katherine Garman, MD, associate professor of medicine and vice chief of research, gastroenterology, at Duke University, Durham, N.C., offered ways to incorporate ergonomics into an endoscopy training curriculum.

“Ergonomics evaluates how a job can best fit to an individual, instead of forcing an individual to fit into a job,” Dr. Garman said. “[This] is a really important concept when we think about training,”

Yet this concept may run counter to most fellows’ natural instinct to fit in and avoid being obtrusive, she noted.

“We need to think about empowering [fellows] from the very beginning to be proactive about how [they] interact with the equipment and the space,” Dr. Garman said. “[They should know] it is perfectly acceptable to adjust the monitor height, move the bed height to an appropriate level, and make the space comfortable ... at the beginning of what should be a long, productive career.”

Dr. Garman offered several more key points to include in a training program, including increased postural awareness, microbreaks during procedures, and early intervention for prior injuries that may increase risk.

“We’ve had fellows who’ve come in who’ve had fractures, wrist [injuries], shoulder injuries,” she said. “We advise early consultation with a physical therapist for those fellows.”

In a recently published study, Dr. Garman and colleagues invited a physical therapist into the endoscopy suite, allowing for real-time assessment of ergonomic positioning and posturing, as well as wellness planning. Out of eight participating endoscopists, all said that the posture education and procedure suite recommendations were helpful, 87.5% said that the pictures of their posture and movement analysis were helpful, 50% said that the pain education was helpful, and 25% found the personalized exercise plans helpful.

“Endoscopists are not always excited about doing exercises at home,” Dr. Garman said.
 

The ergonomically optimized endoscopy suite

In the next presentation, Mehnaz Shafi, MD, professor of medicine and ad interim chair of the department of gastroenterology, hepatology, and nutrition at MD Anderson Cancer Center, Houston, described how clinicians and institutions can create ergonomically optimized endoscopy suites.

She began by reviewing specific causes of injury, including repetitive motion, high pinch force, and awkward posture, the latter of which can lead to microtrauma, inflammation, and connective tissue injury.

According to Dr. Shafi, endoscopists should stand in a neutral position with back straight and knees slightly bent. The patient should be positioned at the edge of the bed, which should be 85-120 cm off the floor. Monitors should be 93-162 cm off the floor and 15-25 degrees below eye level. When interacting with multiple monitors, endoscopists should rotate their entire bodies to maintain a neutral position. Hands and elbows also should be kept neutral, with less than 10 degrees of angulation from the height of the bed. To ensure safer hand grip, Dr. Shafi suggested removing any cord loops that may increase tension and using a towel to more evenly distribute gripping force.

Finally, Dr. Shafi encouraged awareness of other room hazards, such as slippery floors and exposed wires and tubing.

The presenters reported having no conflicts of interest.

This article was updated May 5, 2021.

Endoscopists are at high risk of musculoskeletal issues, and a multifaceted strategy is needed to reduce rates of injury, including better body posture and endoscopic suite layout, according to leading experts.

Andrey Shevchuk/iStock/Getty Images

Latha Alaparthi, MD, director of committee operations at Gastroenterology Center of Connecticut, Hamden, and assistant clinical professor at Yale University, New Haven, Conn., noted that female gastroenterologists are at particular risk because they often work with outsize equipment and suboptimal room setup.

“I think it’s something for us to recognize, and [we need to] find ways to protect ourselves,” Dr. Alaparthi said during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.
 

Prevalence of musculoskeletal injuries in gastroenterology

Gastroenterologists spend 43% of their time performing procedures, Dr. Alaparthi said, and all those hours take a toll on the body. Up to 89% of gastroenterologists report musculoskeletal symptoms – most often back pain, followed by neck pain and hand pain.

Even newcomers to the field are at risk, she added, noting that 47% of gastroenterology fellows report injury in their first year of training. And with one out of three fellows now female, the issue may be a growing concern.

“As female gastroenterologists, we are even more at risk,” Dr. Alaparthi said. This is partly due to differences in equipment and room design, which “take into consideration 5% of female average measurements and 95% of that of males.”

The resultant injuries may be enough to drive female doctors from the field. Dr. Alaparthi recounted her colleague’s experience in leaving gastroenterology for the pharmaceutical industry after experiencing ongoing neck pain.

“She called me and said 1 week after she stopped doing endoscopies, her neck pain was gone.”

For gastroenterologists of any gender, musculoskeletal injuries can cause pain and suffering, reduced quality of life, lost or reduced work output, short-term or permanent disability, lost wages, and impediment to career advancement. Yet physicians aren’t the only stakeholders affected by these injuries. Employers stand to lose financially from decreased productivity and increased compensation costs.

“[Injuries have] implications not just to the individual but to the company and to patient care,” Dr. Alaparthi said.

She went on to suggest that an effective solution to the problem will require efforts from both gastroenterologists and institutions, including greater self-awareness of body positioning, access to anthropometrically suitable equipment, better room design, and a work culture that supports breaks during procedures, if needed.

“We definitely need programs to provide comprehensive work force injury prevention and protection specific to GI endoscopy – not just for gastroenterologists, but for the whole team involved.”

Ergonomics in endoscopy training

Presenting after Dr. Alaparthi, Katherine Garman, MD, associate professor of medicine and vice chief of research, gastroenterology, at Duke University, Durham, N.C., offered ways to incorporate ergonomics into an endoscopy training curriculum.

“Ergonomics evaluates how a job can best fit to an individual, instead of forcing an individual to fit into a job,” Dr. Garman said. “[This] is a really important concept when we think about training,”

Yet this concept may run counter to most fellows’ natural instinct to fit in and avoid being obtrusive, she noted.

“We need to think about empowering [fellows] from the very beginning to be proactive about how [they] interact with the equipment and the space,” Dr. Garman said. “[They should know] it is perfectly acceptable to adjust the monitor height, move the bed height to an appropriate level, and make the space comfortable ... at the beginning of what should be a long, productive career.”

Dr. Garman offered several more key points to include in a training program, including increased postural awareness, microbreaks during procedures, and early intervention for prior injuries that may increase risk.

“We’ve had fellows who’ve come in who’ve had fractures, wrist [injuries], shoulder injuries,” she said. “We advise early consultation with a physical therapist for those fellows.”

In a recently published study, Dr. Garman and colleagues invited a physical therapist into the endoscopy suite, allowing for real-time assessment of ergonomic positioning and posturing, as well as wellness planning. Out of eight participating endoscopists, all said that the posture education and procedure suite recommendations were helpful, 87.5% said that the pictures of their posture and movement analysis were helpful, 50% said that the pain education was helpful, and 25% found the personalized exercise plans helpful.

“Endoscopists are not always excited about doing exercises at home,” Dr. Garman said.
 

The ergonomically optimized endoscopy suite

In the next presentation, Mehnaz Shafi, MD, professor of medicine and ad interim chair of the department of gastroenterology, hepatology, and nutrition at MD Anderson Cancer Center, Houston, described how clinicians and institutions can create ergonomically optimized endoscopy suites.

She began by reviewing specific causes of injury, including repetitive motion, high pinch force, and awkward posture, the latter of which can lead to microtrauma, inflammation, and connective tissue injury.

According to Dr. Shafi, endoscopists should stand in a neutral position with back straight and knees slightly bent. The patient should be positioned at the edge of the bed, which should be 85-120 cm off the floor. Monitors should be 93-162 cm off the floor and 15-25 degrees below eye level. When interacting with multiple monitors, endoscopists should rotate their entire bodies to maintain a neutral position. Hands and elbows also should be kept neutral, with less than 10 degrees of angulation from the height of the bed. To ensure safer hand grip, Dr. Shafi suggested removing any cord loops that may increase tension and using a towel to more evenly distribute gripping force.

Finally, Dr. Shafi encouraged awareness of other room hazards, such as slippery floors and exposed wires and tubing.

The presenters reported having no conflicts of interest.

This article was updated May 5, 2021.

Endoscopists are at high risk of musculoskeletal issues, and a multifaceted strategy is needed to reduce rates of injury, including better body posture and endoscopic suite layout, according to leading experts.

Andrey Shevchuk/iStock/Getty Images

Latha Alaparthi, MD, director of committee operations at Gastroenterology Center of Connecticut, Hamden, and assistant clinical professor at Yale University, New Haven, Conn., noted that female gastroenterologists are at particular risk because they often work with outsize equipment and suboptimal room setup.

“I think it’s something for us to recognize, and [we need to] find ways to protect ourselves,” Dr. Alaparthi said during a virtual presentation at the 2021 AGA Tech Summit sponsored by the AGA Center for GI Innovation and Technology.
 

Prevalence of musculoskeletal injuries in gastroenterology

Gastroenterologists spend 43% of their time performing procedures, Dr. Alaparthi said, and all those hours take a toll on the body. Up to 89% of gastroenterologists report musculoskeletal symptoms – most often back pain, followed by neck pain and hand pain.

Even newcomers to the field are at risk, she added, noting that 47% of gastroenterology fellows report injury in their first year of training. And with one out of three fellows now female, the issue may be a growing concern.

“As female gastroenterologists, we are even more at risk,” Dr. Alaparthi said. This is partly due to differences in equipment and room design, which “take into consideration 5% of female average measurements and 95% of that of males.”

The resultant injuries may be enough to drive female doctors from the field. Dr. Alaparthi recounted her colleague’s experience in leaving gastroenterology for the pharmaceutical industry after experiencing ongoing neck pain.

“She called me and said 1 week after she stopped doing endoscopies, her neck pain was gone.”

For gastroenterologists of any gender, musculoskeletal injuries can cause pain and suffering, reduced quality of life, lost or reduced work output, short-term or permanent disability, lost wages, and impediment to career advancement. Yet physicians aren’t the only stakeholders affected by these injuries. Employers stand to lose financially from decreased productivity and increased compensation costs.

“[Injuries have] implications not just to the individual but to the company and to patient care,” Dr. Alaparthi said.

She went on to suggest that an effective solution to the problem will require efforts from both gastroenterologists and institutions, including greater self-awareness of body positioning, access to anthropometrically suitable equipment, better room design, and a work culture that supports breaks during procedures, if needed.

“We definitely need programs to provide comprehensive work force injury prevention and protection specific to GI endoscopy – not just for gastroenterologists, but for the whole team involved.”

Ergonomics in endoscopy training

Presenting after Dr. Alaparthi, Katherine Garman, MD, associate professor of medicine and vice chief of research, gastroenterology, at Duke University, Durham, N.C., offered ways to incorporate ergonomics into an endoscopy training curriculum.

“Ergonomics evaluates how a job can best fit to an individual, instead of forcing an individual to fit into a job,” Dr. Garman said. “[This] is a really important concept when we think about training,”

Yet this concept may run counter to most fellows’ natural instinct to fit in and avoid being obtrusive, she noted.

“We need to think about empowering [fellows] from the very beginning to be proactive about how [they] interact with the equipment and the space,” Dr. Garman said. “[They should know] it is perfectly acceptable to adjust the monitor height, move the bed height to an appropriate level, and make the space comfortable ... at the beginning of what should be a long, productive career.”

Dr. Garman offered several more key points to include in a training program, including increased postural awareness, microbreaks during procedures, and early intervention for prior injuries that may increase risk.

“We’ve had fellows who’ve come in who’ve had fractures, wrist [injuries], shoulder injuries,” she said. “We advise early consultation with a physical therapist for those fellows.”

In a recently published study, Dr. Garman and colleagues invited a physical therapist into the endoscopy suite, allowing for real-time assessment of ergonomic positioning and posturing, as well as wellness planning. Out of eight participating endoscopists, all said that the posture education and procedure suite recommendations were helpful, 87.5% said that the pictures of their posture and movement analysis were helpful, 50% said that the pain education was helpful, and 25% found the personalized exercise plans helpful.

“Endoscopists are not always excited about doing exercises at home,” Dr. Garman said.
 

The ergonomically optimized endoscopy suite

In the next presentation, Mehnaz Shafi, MD, professor of medicine and ad interim chair of the department of gastroenterology, hepatology, and nutrition at MD Anderson Cancer Center, Houston, described how clinicians and institutions can create ergonomically optimized endoscopy suites.

She began by reviewing specific causes of injury, including repetitive motion, high pinch force, and awkward posture, the latter of which can lead to microtrauma, inflammation, and connective tissue injury.

According to Dr. Shafi, endoscopists should stand in a neutral position with back straight and knees slightly bent. The patient should be positioned at the edge of the bed, which should be 85-120 cm off the floor. Monitors should be 93-162 cm off the floor and 15-25 degrees below eye level. When interacting with multiple monitors, endoscopists should rotate their entire bodies to maintain a neutral position. Hands and elbows also should be kept neutral, with less than 10 degrees of angulation from the height of the bed. To ensure safer hand grip, Dr. Shafi suggested removing any cord loops that may increase tension and using a towel to more evenly distribute gripping force.

Finally, Dr. Shafi encouraged awareness of other room hazards, such as slippery floors and exposed wires and tubing.

The presenters reported having no conflicts of interest.

This article was updated May 5, 2021.

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

Primary care providers can confidently pick any of three cervical cancer screening strategies recommended by the American Cancer Society and the United States Preventive Services Task Force, experts said.

Cytology testing every 3 years, cytology/human papillomavirus cotesting every 5 years, and primary HPV testing every 5 years are similarly effective at reducing cervical cancer risk, said Rachel P. Brook, MD, of the University of California, Los Angeles Health Iris Cantor Women’s Health Center, during a presentation at the annual meeting of the American College of Physicians.

“The most important thing a primary care provider can do is to screen with whatever test is most accessible,” Dr. Brook said in an interview. She also noted that access to screening remains a pressing concern, particularly among underrepresented groups and women in rural areas. Even when women can access testing, follow-up after abnormal results can be inadequate, leading to increased risk of cervical cancer mortality.

To address some of these shortcomings, Dr. Brook provided an overview of current guidelines and appropriate responses to abnormal test results.

First, during her presentation, she noted that guideline recommendations do not apply to patients with additional risk factors, including a compromised immune system, HIV infection, previous treatment of cervical cancer or a high-grade cancerous lesion, or in utero exposure to diethylstilbestrol.

“This is very important,” Dr. Brook said during her presentation. “They should receive individualized care due to their above average risk of cervical cancer.”

Among women with average risk, both the USPSTF 2018 guideline and the ACS 2020 guideline recommend against screening women aged less than 21 years.

In a major change to the most recent ACS guideline, screening women aged 21-24 years is no longer recommended, in contrast with the USPSTF guideline, which still calls for cytology every 3 years for this age group. This recommendation by the USPSTF extends to women aged 25-29 years, a group for which the ACS recommends primary HPV testing every 5 years, cytology/HPV cotesting every 5 years, or cytology testing every 3 years. For both organizations, any of these three testing methods is recommended for women aged 30-65 years, followed by discontinuation of testing after 65 years, given adequate prior screening.

“For all these recommendations and guidelines, they’re pertinent to patients regardless of HPV vaccination status,” Dr. Brook said. But she added that increased rates of HPV vaccination may affect future screening guidelines, as vaccinated patients are more likely to have false positive cytology results because of low-risk HPV strains. This trend may steer future recommendations toward primary HPV testing, Dr. Brook said.

Presently, for applicable age groups, the ACS guideline favors HPV testing alone over cytology alone or cotesting, whereas the USPSTF guideline offers no preference between the three testing strategies.
 

Primary HPV vs. cytology testing

Dr. Brook said a single negative HPV test provides more than 95% assurance that a patient will not develop cervical cancer or a cancer precursor within the next 5 years. One negative HPV test offers similar reliability to about 3 negative cytology tests.

Switching to a 5-year testing cycle may be unsettling for patients who are used to getting a Pap test every year, but having a conversation about test accuracy can help assuage patient concerns, she said.

Still, Dr. Brook emphasized that any of the three testing strategies is ultimately acceptable.

“The take-home message here is – truly – that any of the recommended screening options will greatly reduce cervical cancer risk,” Dr. Brook said. “So, screen. And if there is any confusion or concern with your patients about which [screening strategy to use], just help them decide on any of the three. But please screen.”
 

Self-swabbing could improve screening in certain groups

To improve screening rates, particularly for women with poor access and those averse to a speculum exam, Dr. Brook highlighted self-swabbing primary HPV tests, which may soon be available. While no self-swabbing HPV tests are yet approved by the Food and Drug Administration, they offer a 76% sensitivity rate for cervical intraepithelial neoplasia grade 2, and a rate of 85% for CIN3, compared with 91% for physician-collected samples.

Regardless of the exact HPV test, Dr. Brook advised appropriate reflex testing.

“We need to make sure all primary HPV screening tests positive for types other than HPV-16 or -18 will require additional reflex triage testing with cytology,” Dr. Brook said in interview. “If not – if a woman has a primary HPV screening test that is positive and I cannot perform reflex cytology – I have to bring her back for an additional test and speculum exam to get cytology, which is an unnecessary burden to the patient, and also increases testing.”

Kathy L. MacLaughlin, MD, associate professor of family medicine at Mayo Clinic, Rochester, Minn., said this is one drawback to self-swabbing tests in an interview.

“If there is a positive HPV result [with a self-swabbing test], the patient will need to have a clinic appointment for Pap collection [if one of the ‘other’ 12 HPV types are identified], or be referred for a colposcopy [if HPV types 16 or 18 are identified],” Dr. MacLaughlin said. “There need to be plans in place for access to those services.”

Incidentally, it may be women who face barriers to access that need self-swabbing HPV tests the most, according to Dr. MacLaughlin.

“I think there is significant potential to improve screening rates among never-screened and underscreened women and those are the groups for whom this makes the most sense,” she said. “I don’t think anyone is suggesting that women who have the means and interest in scheduling a face-to-face visit for clinician-collected screening switch to self-screening, but it is a promising option [once FDA approved] for reaching other women and reducing disparities in screening rates.”

Dr. MacLaughlin suggested that self-screening programs could operate outside of normal business hours in a variety of settings, such as homes, community centers, and churches.

Until self-screening is an option, Dr. MacLaughlin agreed with Dr. Brook that any of the three testing strategies is suitable for screening, and recommended that primary care providers seize the opportunities presented to them.

“Individual primary care providers can improve screening rates by offering to update cervical cancer screening at a clinic appointment even if that was not the primary indication for the visit, especially for women who are long overdue,” Dr. MacLaughlin said. “If there is just no time to fit in the screening or the patient declines, then order a return visit and have the patient stop at the appointment desk as they leave.”

“I recognize we are asked to fit in more and more in less time, but I’ve found this to be effective when I have capacity in the clinic day to offer it,” she added.

Dr. Brook and Dr. MacLaughlin reported no conflicts of interest.

Primary care providers can confidently pick any of three cervical cancer screening strategies recommended by the American Cancer Society and the United States Preventive Services Task Force, experts said.

Cytology testing every 3 years, cytology/human papillomavirus cotesting every 5 years, and primary HPV testing every 5 years are similarly effective at reducing cervical cancer risk, said Rachel P. Brook, MD, of the University of California, Los Angeles Health Iris Cantor Women’s Health Center, during a presentation at the annual meeting of the American College of Physicians.

“The most important thing a primary care provider can do is to screen with whatever test is most accessible,” Dr. Brook said in an interview. She also noted that access to screening remains a pressing concern, particularly among underrepresented groups and women in rural areas. Even when women can access testing, follow-up after abnormal results can be inadequate, leading to increased risk of cervical cancer mortality.

To address some of these shortcomings, Dr. Brook provided an overview of current guidelines and appropriate responses to abnormal test results.

First, during her presentation, she noted that guideline recommendations do not apply to patients with additional risk factors, including a compromised immune system, HIV infection, previous treatment of cervical cancer or a high-grade cancerous lesion, or in utero exposure to diethylstilbestrol.

“This is very important,” Dr. Brook said during her presentation. “They should receive individualized care due to their above average risk of cervical cancer.”

Among women with average risk, both the USPSTF 2018 guideline and the ACS 2020 guideline recommend against screening women aged less than 21 years.

In a major change to the most recent ACS guideline, screening women aged 21-24 years is no longer recommended, in contrast with the USPSTF guideline, which still calls for cytology every 3 years for this age group. This recommendation by the USPSTF extends to women aged 25-29 years, a group for which the ACS recommends primary HPV testing every 5 years, cytology/HPV cotesting every 5 years, or cytology testing every 3 years. For both organizations, any of these three testing methods is recommended for women aged 30-65 years, followed by discontinuation of testing after 65 years, given adequate prior screening.

“For all these recommendations and guidelines, they’re pertinent to patients regardless of HPV vaccination status,” Dr. Brook said. But she added that increased rates of HPV vaccination may affect future screening guidelines, as vaccinated patients are more likely to have false positive cytology results because of low-risk HPV strains. This trend may steer future recommendations toward primary HPV testing, Dr. Brook said.

Presently, for applicable age groups, the ACS guideline favors HPV testing alone over cytology alone or cotesting, whereas the USPSTF guideline offers no preference between the three testing strategies.
 

Primary HPV vs. cytology testing

Dr. Brook said a single negative HPV test provides more than 95% assurance that a patient will not develop cervical cancer or a cancer precursor within the next 5 years. One negative HPV test offers similar reliability to about 3 negative cytology tests.

Switching to a 5-year testing cycle may be unsettling for patients who are used to getting a Pap test every year, but having a conversation about test accuracy can help assuage patient concerns, she said.

Still, Dr. Brook emphasized that any of the three testing strategies is ultimately acceptable.

“The take-home message here is – truly – that any of the recommended screening options will greatly reduce cervical cancer risk,” Dr. Brook said. “So, screen. And if there is any confusion or concern with your patients about which [screening strategy to use], just help them decide on any of the three. But please screen.”
 

Self-swabbing could improve screening in certain groups

To improve screening rates, particularly for women with poor access and those averse to a speculum exam, Dr. Brook highlighted self-swabbing primary HPV tests, which may soon be available. While no self-swabbing HPV tests are yet approved by the Food and Drug Administration, they offer a 76% sensitivity rate for cervical intraepithelial neoplasia grade 2, and a rate of 85% for CIN3, compared with 91% for physician-collected samples.

Regardless of the exact HPV test, Dr. Brook advised appropriate reflex testing.

“We need to make sure all primary HPV screening tests positive for types other than HPV-16 or -18 will require additional reflex triage testing with cytology,” Dr. Brook said in interview. “If not – if a woman has a primary HPV screening test that is positive and I cannot perform reflex cytology – I have to bring her back for an additional test and speculum exam to get cytology, which is an unnecessary burden to the patient, and also increases testing.”

Kathy L. MacLaughlin, MD, associate professor of family medicine at Mayo Clinic, Rochester, Minn., said this is one drawback to self-swabbing tests in an interview.

“If there is a positive HPV result [with a self-swabbing test], the patient will need to have a clinic appointment for Pap collection [if one of the ‘other’ 12 HPV types are identified], or be referred for a colposcopy [if HPV types 16 or 18 are identified],” Dr. MacLaughlin said. “There need to be plans in place for access to those services.”

Incidentally, it may be women who face barriers to access that need self-swabbing HPV tests the most, according to Dr. MacLaughlin.

“I think there is significant potential to improve screening rates among never-screened and underscreened women and those are the groups for whom this makes the most sense,” she said. “I don’t think anyone is suggesting that women who have the means and interest in scheduling a face-to-face visit for clinician-collected screening switch to self-screening, but it is a promising option [once FDA approved] for reaching other women and reducing disparities in screening rates.”

Dr. MacLaughlin suggested that self-screening programs could operate outside of normal business hours in a variety of settings, such as homes, community centers, and churches.

Until self-screening is an option, Dr. MacLaughlin agreed with Dr. Brook that any of the three testing strategies is suitable for screening, and recommended that primary care providers seize the opportunities presented to them.

“Individual primary care providers can improve screening rates by offering to update cervical cancer screening at a clinic appointment even if that was not the primary indication for the visit, especially for women who are long overdue,” Dr. MacLaughlin said. “If there is just no time to fit in the screening or the patient declines, then order a return visit and have the patient stop at the appointment desk as they leave.”

“I recognize we are asked to fit in more and more in less time, but I’ve found this to be effective when I have capacity in the clinic day to offer it,” she added.

Dr. Brook and Dr. MacLaughlin reported no conflicts of interest.

Primary care providers can confidently pick any of three cervical cancer screening strategies recommended by the American Cancer Society and the United States Preventive Services Task Force, experts said.

Cytology testing every 3 years, cytology/human papillomavirus cotesting every 5 years, and primary HPV testing every 5 years are similarly effective at reducing cervical cancer risk, said Rachel P. Brook, MD, of the University of California, Los Angeles Health Iris Cantor Women’s Health Center, during a presentation at the annual meeting of the American College of Physicians.

“The most important thing a primary care provider can do is to screen with whatever test is most accessible,” Dr. Brook said in an interview. She also noted that access to screening remains a pressing concern, particularly among underrepresented groups and women in rural areas. Even when women can access testing, follow-up after abnormal results can be inadequate, leading to increased risk of cervical cancer mortality.

To address some of these shortcomings, Dr. Brook provided an overview of current guidelines and appropriate responses to abnormal test results.

First, during her presentation, she noted that guideline recommendations do not apply to patients with additional risk factors, including a compromised immune system, HIV infection, previous treatment of cervical cancer or a high-grade cancerous lesion, or in utero exposure to diethylstilbestrol.

“This is very important,” Dr. Brook said during her presentation. “They should receive individualized care due to their above average risk of cervical cancer.”

Among women with average risk, both the USPSTF 2018 guideline and the ACS 2020 guideline recommend against screening women aged less than 21 years.

In a major change to the most recent ACS guideline, screening women aged 21-24 years is no longer recommended, in contrast with the USPSTF guideline, which still calls for cytology every 3 years for this age group. This recommendation by the USPSTF extends to women aged 25-29 years, a group for which the ACS recommends primary HPV testing every 5 years, cytology/HPV cotesting every 5 years, or cytology testing every 3 years. For both organizations, any of these three testing methods is recommended for women aged 30-65 years, followed by discontinuation of testing after 65 years, given adequate prior screening.

“For all these recommendations and guidelines, they’re pertinent to patients regardless of HPV vaccination status,” Dr. Brook said. But she added that increased rates of HPV vaccination may affect future screening guidelines, as vaccinated patients are more likely to have false positive cytology results because of low-risk HPV strains. This trend may steer future recommendations toward primary HPV testing, Dr. Brook said.

Presently, for applicable age groups, the ACS guideline favors HPV testing alone over cytology alone or cotesting, whereas the USPSTF guideline offers no preference between the three testing strategies.
 

Primary HPV vs. cytology testing

Dr. Brook said a single negative HPV test provides more than 95% assurance that a patient will not develop cervical cancer or a cancer precursor within the next 5 years. One negative HPV test offers similar reliability to about 3 negative cytology tests.

Switching to a 5-year testing cycle may be unsettling for patients who are used to getting a Pap test every year, but having a conversation about test accuracy can help assuage patient concerns, she said.

Still, Dr. Brook emphasized that any of the three testing strategies is ultimately acceptable.

“The take-home message here is – truly – that any of the recommended screening options will greatly reduce cervical cancer risk,” Dr. Brook said. “So, screen. And if there is any confusion or concern with your patients about which [screening strategy to use], just help them decide on any of the three. But please screen.”
 

Self-swabbing could improve screening in certain groups

To improve screening rates, particularly for women with poor access and those averse to a speculum exam, Dr. Brook highlighted self-swabbing primary HPV tests, which may soon be available. While no self-swabbing HPV tests are yet approved by the Food and Drug Administration, they offer a 76% sensitivity rate for cervical intraepithelial neoplasia grade 2, and a rate of 85% for CIN3, compared with 91% for physician-collected samples.

Regardless of the exact HPV test, Dr. Brook advised appropriate reflex testing.

“We need to make sure all primary HPV screening tests positive for types other than HPV-16 or -18 will require additional reflex triage testing with cytology,” Dr. Brook said in interview. “If not – if a woman has a primary HPV screening test that is positive and I cannot perform reflex cytology – I have to bring her back for an additional test and speculum exam to get cytology, which is an unnecessary burden to the patient, and also increases testing.”

Kathy L. MacLaughlin, MD, associate professor of family medicine at Mayo Clinic, Rochester, Minn., said this is one drawback to self-swabbing tests in an interview.

“If there is a positive HPV result [with a self-swabbing test], the patient will need to have a clinic appointment for Pap collection [if one of the ‘other’ 12 HPV types are identified], or be referred for a colposcopy [if HPV types 16 or 18 are identified],” Dr. MacLaughlin said. “There need to be plans in place for access to those services.”

Incidentally, it may be women who face barriers to access that need self-swabbing HPV tests the most, according to Dr. MacLaughlin.

“I think there is significant potential to improve screening rates among never-screened and underscreened women and those are the groups for whom this makes the most sense,” she said. “I don’t think anyone is suggesting that women who have the means and interest in scheduling a face-to-face visit for clinician-collected screening switch to self-screening, but it is a promising option [once FDA approved] for reaching other women and reducing disparities in screening rates.”

Dr. MacLaughlin suggested that self-screening programs could operate outside of normal business hours in a variety of settings, such as homes, community centers, and churches.

Until self-screening is an option, Dr. MacLaughlin agreed with Dr. Brook that any of the three testing strategies is suitable for screening, and recommended that primary care providers seize the opportunities presented to them.

“Individual primary care providers can improve screening rates by offering to update cervical cancer screening at a clinic appointment even if that was not the primary indication for the visit, especially for women who are long overdue,” Dr. MacLaughlin said. “If there is just no time to fit in the screening or the patient declines, then order a return visit and have the patient stop at the appointment desk as they leave.”

“I recognize we are asked to fit in more and more in less time, but I’ve found this to be effective when I have capacity in the clinic day to offer it,” she added.

Dr. Brook and Dr. MacLaughlin reported no conflicts of interest.