An Estimate of Severe Harms Due to Screening Colonoscopy
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
This study aims to comprehensively assess the direct, severe harms of screening colonoscopy in the United States. Whereas other investigators have completed systematic reviews estimating the harms of all types of colonoscopy, this analysis focuses on screening colonoscopies that had adequate follow up to avoid undercounting delayed harms.
DATA SOURCES
PubMed and Embase were queried for relevant studies on screening colonoscopy harms published between January 1, 2002, and April 1, 2022.
STUDY SELECTION
English-language studies of screening colonoscopy for average risk patients were included. Studies must have followed patients for adequate time post procedure, defined as 30 days after colonoscopy.
MAIN OUTCOMES
The primary outcome was the number of severe bleeding events and gastrointestinal (GI) perforations within 30 days of screening colonoscopy.
RESULTS
A total of 1951 studies were reviewed for inclusion; 94 were reviewed in full text. Of those reviewed in full, 6 studies, including a total of 467,139 colonoscopies, met our inclusion criteria and were included in our analysis of harms related to screening colonoscopies. The rate of severe bleeding ranged credibly from 16.4 to 36.18 per 10,000 colonoscopies; the rate of perforation ranged credibly from 7.62 to 8.50 per 10,000 colonoscopies.
CONCLUSIONS
This study is the first to estimate direct harms from screening colonoscopy, including harms that occur up to 30 days after the procedure. The risk of harm subsequent to screening colonoscopy is higher than previously reported and should be discussed with patients when engaging in shared decision making.
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Additional Info
Disclosure statements are available on the authors' profiles:
An Estimate of Severe Harms Due to Screening Colonoscopy: A Systematic Review
J Am Board Fam Med 2023 May 08;36(3)493-500, AN Huffstetler, J Fraiman, S Brownlee, MA Stoto, KW LinFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Screening for colorectal cancer in average-risk individuals can cause harm
In my average day of clinical care, I offer 4 patients options for colorectal cancer screening. Often, with some knowledge or prior experience, we dive into the nuances of screening options. It took me at least 4 years to caress my monologue into a dialogue that does not result in an eyes-glazed-over look due to information saturation.
Our dialogue results in shared decision–making – that shared decision–making is based on the best available evidence and values of the person in front of me. The recommended screening options for colorectal cancer include colonoscopy, flexible sigmoidoscopy, CT colonography, and stool-based tests such as FIT. The risks of colonoscopy cited by the USPSTF in their 2021 update are 17.5 serious bleeding events and 5.4 perforations per 10,000 colonoscopies.1 We review the benefit of colonoscopy; identification of precancerous lesions and a longer interval for repeat if findings are normal.1
This systematic review explored harms related to screening colonoscopies and differed from prior literature in two specific ways: 1) exclusively included screening colonoscopies (not those done for diagnostic purposes or for individuals with high-risk characteristics) and 2) followed individuals for at least 30 days after screening. Colonoscopies that included polypectomies were included, as they are often performed in the setting of screening colonoscopies.
In total, six studies including 467,139 screening colonoscopies were included. Harms were higher than those found in prior systematic reviews, with credible ranges of 16.4 to 36.19 for serious bleeding events and for 7.62 to 8.50 perforations per 10,000 colonoscopies.
Any medical intervention poses risks; as clinicians, we balance these risks with the benefits with the patients’ personal values. Serious bleeding and perforations are not uncommon after colonoscopies and should be explicitly communicated to patients. Screening should still take place, and patients often choose colonoscopy. However, communicating accurate, timely, and realistic risk is essential to shared decision–making.
References