Colorectal cancer is the second leading cause of cancer death in the USA.1
Colorectal cancer screening performed with flexible sigmoidoscopy (FS) has been associated with reduced incidence and mortality from colorectal cancer in cohort studies,2
case control studies,3–7
and a randomised controlled trial.8
FS is performed in diverse environments, including dedicated hospital based endoscopy units, outpatient physician offices, and endoscopic ambulatory surgery centres.
FS is a complex technical procedure that requires training and experience to ensure accuracy and safety.9
The US Multi-Society Task Force on Colorectal Cancer developed these recommendations for the technical performance of FS and for continuous quality improvement in FS screening in conjunction with several international experts on the use of FS. The Task Force is comprised of representatives of the American College of Gastroenterology, the American College of Physicians-American Society of Internal Medicine, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy (ASGE). Investigators performing three large randomised clinical trials of FS provided additional expert opinion (prostate, lung, colorectal, and ovarian trial of the US National Cancer Institute (Robert E Schoen),10,11
the UK Flexible Sigmoidoscopy Trial (Wendy Atkin),12
and the Norwegian Colorectal Cancer Prevention trial (Geir Hoff)13,14
The focus of these recommendations is on the quality of FS in relation to screening and prevention of colorectal cancer. Thus the recommendations do not address every diagnostic or therapeutic use of FS. These recommendations address the intervals between FS examinations, documentation of results, training of endoscopists, decision making around referral for colonoscopy, policies for antibiotic prophylaxis and management of anticoagulation, insertion of the FS endoscope, bowel preparation, complications, the use of non-physicians as FS endoscopists, and FS endoscope reprocessing. For each of these areas, the underlying evidence base is reviewed, continuous quality improvement targets are recommended, and research questions are proposed (tables 1, 2).
Table 1 Continuous quality improvement targets
Table 2 Areas for future research related to performance of flexible sigmoidoscopy
The purpose of this paper is: (1) to provide evidence and consensus based standards for the performance of high quality screening FS and (2) to facilitate the development of constructive programmes in continuous quality improvement. Continuous quality improvement should be part of every FS screening programme.
We propose the following course of action for endoscopists found to have substandard performance, given the limitations of the current evidence base, understanding the danger of misjudging the results of patient selection as poor performance. Merely providing feedback on individual performance can be expected to result in significant improvement in performance, for individuals and collectively for all endoscopists involved. Endoscopists with suboptimal performance, who fail to improve after feedback of information, may require more direct intervention. The exact mechanism of this intervention has not been well studied. For these types of programmes to be successful it is crucial to explicitly state that the aim is not to punish. The responsibility for improvement of individual practitioners lies with the institution in which they practice, to provide opportunities to reach a sufficient level of proficiency by learning from other colleagues or attending formal courses. In the end, there may remain a small group of individuals unable or unwilling to take the necessary course of action to improve. The best method of dealing with these providers will have to be made on a case by case basis.