Endoscopists oppose radiologists’ push for virtual colonoscopy

Cancer

By Mardi Chapman

13 Jul 2018

Radiologists are renewing a push to widen access to CT colonography (CTC), which they say is needed to relieve pressure on colonoscopy waiting lists.

The Royal Australian and New Zealand College of Radiologists (RANZCR) has indicated it will reapply to the Medical Services Advisory Committee (MSAC) to expand access to CT colonography (CTC) with a new Medicare item “for patients with inadequate access to colonoscopy, such as to cause delay in diagnosis”.

A previous application to open Medicare-reimbursed CTC to patients, other than those who have failed or have a contraindication to colonoscopy, was rejected by MSAC in 2014.

The College says MSAC’s refusal means patients have to join an ever-expanding colonoscopy waiting list and risk “potentially life threatening consequences” of a delayed diagnosis of bowel cancer, or pay privately for CTC.

It cites 2018 data from the AIHW, showing that some patients are waiting significantly longer than the recommended 120 days for colonoscopy after a positive FOBT, was reason enough for change.

“With the majority of Australian bowel cancer patients facing increasing times for diagnosis and treatment, RANZCR calls on the Federal Government to review the rebate policy and improve access to CTC,” RANZCR president Dr Lance Lawler says.

However RANZCR may not receive much support from medical and surgical colleagues.

Chair of the Australian Gastrointestinal Endoscopy Association Associate Professor William Tam said adopting CTC would represent a paradigm shift from the current model of care.

“At the moment there is a good reason why CTC is reserved only for cases where you have failed colonoscopy because you can only reliably detect polyps greater than 1 cm in size and there are no population studies to suggest this is effective strategy to deal with patients with a positive FOBT.”

He said he would prefer to see systematic efforts to identify and address the reasons behind long waiting lists for colonoscopy.

“And, by and large, that is not related to not having enough people to do it. It’s not so much a manpower issue like the UK or the US where there is a lack of people to do the test.”

“We actually have enough proceduralists to do the procedure. What we do not have is the support infrastructure – the anaesthetic staff, the nursing staff, the endoscopy rooms to be able to increase our load.”

President of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) Mr James Keck said CTC was very good at picking up polyps greater than 1 cm in size, would identify some polyps between 0.5 cm and 1 cm but was not helpful for small polyps less than 0.5 cm.

In addition, CTC doesn’t allow for any therapeutic activity like polyp removal.

He said roll out of the National Bowel Cancer Screening Program (NBCSP) would generate the need for more colonoscopies in patients with a positive faecal immunochemical test (FIT) where at least half will have a polyp.

“If the risk of a polyp was low CTC is a good screening test but if we know already that at least half the patients having a referral have a polyp then at least half of them will end up having to have two procedures – CTC followed by a colonoscopy.”

He told the limbic the government would be better off trying to improve access to colonoscopy than funding CTC.

“I think the role of CT colonography at the moment is pretty appropriate and seems to work very well.”

“The thing you miss out on with a CTC is the anaesthetic and also you eliminate the very small risk of perforation. But from a patient’s experiential point of view, they still go through a complete bowel clean out which is what seems to upset most of them more than anything else.”

The US Multi-Society Task Force on Colorectal Cancer Screening in 2017 ranked CTC as a second-tier screening test behind first-tier tests of colonoscopy and FIT.

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