Virtual colonoscopy: Perfect storm or chariot of fire?

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CHICAGO—During the Annual Oration in Diagnostic Radiology and Gold Medal Awards presented Tuesday, keynote lecturer Elizabeth McFarland, MD, challenged attendees to “run the enduring race” in the effort to increase CT colonography utilization in the current restrictive reimbursement climate.

McFarland spoke on the topic of CTC, its achievements and challenges and offered up options to the audience as to how to overcome such challenges today.

According to McFarland, since the introduction of CTC in the mid 1990s, there have been tremendous technological gains and validation trials of diagnostic performance pushed the field into a new level of potential. Although CTC can provide a time-efficient, noninvasive structural examination of the whole colon, the many achievements gained are countered by significant challenges to overcome, McFarland noted.

The achievements along the developmental path of CT colonography are many. In the first decade, several facilities were able to attain NCI or corporate funding to pursue the early tasks of optimization of the 3D endoscopic views and CT techniques, along with validation trials of enriched cohorts of patients for detection of colorectal polyps. Novel work in 3D imagery, computer-aided diagnosis, prep-less patient protocols and larger validation trials in screening cohorts followed. “Throughout these efforts, there was a strong culture of investigators, both nationally and internationally, who shared a common passion of the pursuit. Work will start and work will finish, enjoying different levels of peer review, but the culture of the effort will always inspire the future,” McFarland said.

She noted how politics and economics have played an increasing role as CT colonography gained more attention, citing how gastroenterologists became keenly aware of the potential of CT colonography and how it might impact colonoscopy. Continued interactions between the radiology and gastroenterology societies have occurred over the years. The 2008 joint colorectal cancer screening guidelines of the American Cancer Society, US GI Multi-society Task Force, and ACR were a benchmark of multidisciplinary effort. This consensus document updated the recommended list of colorectal screening modalities, with the new adoption of CTC and stool DNA. The economics of CTC will be greatly impacted as third-party payors and CMS now face reimbursement decisions based on new levels of validation and public policy recommendations.

“The key challenge to CTCT in today’s climate is to bring policy and practice into the line with knowledge,” she said.

Key challenges face the future implementation of CTC into the community practice. The pivotal issue of defining what is the target lesion size for polyp detection has stirred much debate. The issues of radiation dose imparted by CT need to be correctly defined, with appropriate quality assurance guidelines of appropriate use.

“There has been mention about training and how do we go out in terms of the current need for colorectal screening with who we have trained for it—and this is what training requires, a one-on-one workstation evaluation across different data sets, across an algorithms of known morphology verified as colonoscopy,” she said, adding that training the next generation of readers, probably both radiologists and gastroenterologists, is clearly underway. “Cost-effectiveness of the effort, within local practices and by third-party payor expectations, needs to be met.”

CT colonography has accomplished tremendous achievements over the last 15 years as a noninvasive colorectal screening modality. However, similar to the challenges of the low-technology field of mammography, the advanced 3D imagery of CT colonography will only face the future challenges of early cancer detection by those who have the disease, McFarland noted.

She suggested that a focus on quality, creating standards for extracolonic findings and more responsibility for radiologists would be ways in which the industry might try to overcome the challenges CTC faces in the current restrictive reimbursement environment. The choice, she said, lays in the hands of the radiologist—to whether the “perfect storm” or to be like famous “Chariots of Fire” runner Eric Liddell and “run the enduring race,” to bring practice and policy in line with knowledge for virtual colonoscopy.