Yes
"Resect and discard" is a policy whereby colorectal polyps smaller than a certain size have their pathology estimated during colonoscopy by an endoscopist using imaging criteria, followed by endoscopic resection of the polyps, after which the polyps are discarded and not sent to the pathology lab. In this country, target polyps are less than 5 mm. In the U.K.: less than 9 mm.
Dr. Douglas K. Rex
For the target polyps in the U.S. the prevalence of villous elements and high-grade dysplasia is very low, and identification of these elements in small polyps is subject to extreme interobserver variation among pathologists (Dig. Liver Dis. 2013;45:1049-55). The prevalence of cancer in polyps less than 5 mm in size is nearly nil (Aliment. Pharmacol. Ther. 2009; 31:210-7; Gastrointest. Endosc. 2012;75:1022-30). Cancer should be endoscopically recognizable in polyps of this size by criteria such as ulceration and disruption of the surface vascular pattern.
Recommendations that CT colonographers ignore polyps less than 5 mm without reporting them (Radiology 2005;236:3-9) are accepted without controversy, while paradoxically, we argue about the wisdom of not sending diminutive polyps to pathology after their pathology has been endoscopically estimated with high confidence and the polyps have then been resected.
Adenoma detection rates (ADRs) are increasing and the cost of pathology evaluation of diminutive polyps is high. Several endoscopic modalities allow accurate estimation of pathology based on image analysis (Lancet Oncol. 2013;14:1337-47). The American Society of Gastrointestinal Endoscopy (ASGE) set a threshold of 90% agreement between postpolypectomy surveillance intervals determined by endoscopists using image analysis and intervals determined by pathology evaluation of all polyps (Gastrointest. Endosc. 2011;73:419-22) to establish resect and discard as an appropriate paradigm for clinical practice. Narrow-band imaging allows endoscopists to achieve the threshold set by ASGE (Gut 2013;62:1704-13) and only a few studies, done primarily by community-based endoscopists with limited training, have failed to meet the ASGE target (Gastroenterology 2013;144:5-8; Gut 2014;63:458-65). Cost analyses show that "resect and discard" could save more than $1 billion per year in the U.S. alone (Endoscopy 2011;43:683-91).
ASGE recommends that polyps be discarded only when pathology is interpreted with high confidence. When a diagnosis is already recognized in clinical practice with high probability, ordering a confirmatory test is considered money wasted. Money is considered well spent when the diagnosis is uncertain, and pathologic interpretation of polyps less than 5 mm in size is a good example.
"Resect and discard" will require endorsement by GI societies, re-education of patients, a credentialing process (given the recent low performance by community endoscopists), creation of training tools, and new documentation schemes based on photography for quality measures such as ADR. Documentation of ADR and medical-legal protection for endoscopists will require storage of high-quality images that record the basis for an endoscopist’s decision. Finally, institutional policies that require submission of resected tissue for pathology will need revision.
Success will depend on aligning the policy with the financial incentives of endoscopists with the introduction of a CPT code for confocal laser microscopy in the United States. Bundled payment, which includes the cost of pathology (Gastroenterology 2014;146:849-53), would create strong motivation for "resect and discard."
Dr. Douglas K. Rex, AGAF, is Distinguished Professor of Medicine, Indiana University School of Medicine, Indianapolis; Chancellor’s Professor, Indiana University–Purdue University Indianapolis; and director of endoscopy, Indiana University Hospital.
No
Dr. Robert H. Riddell
First, standards will be needed for a new diagnostic test. Point of care testing (POCT) is defined as medical diagnostic testing performed outside the clinical laboratory in close proximity to where the patient is receiving care. POCT is typically performed by nonlaboratory personnel and the results are used for clinical decision making. This is therefore a POCT and subject to all of the requirements of POC tests. Accreditation bodies hold departments of pathology accountable for their oversight and quality by Clinical Laboratory Improvement Amendments (CLIA) and the College of American Pathologists (CAP), while input comes from the Food and Drug Administration, Centers for Medicare & Medicaid Services, and the Centers for Disease Control and Prevention.
Second, accreditation will be required to guarantee the quality of all POC tests as well as re-accreditation. Will accreditation be for each endoscopist who will need to demonstrate diagnostic competence, or for each endoscopy unit? How will this be accomplished? At what cost? How will maintenance of competence work?
If one argues there will be no need for accreditation, there will almost certainly be opposition from CLIA, CAP, and numerous other pathologist groups. The obvious argument is that endoscopic assessment does not match up to pathology so it is a substandard test.
