Virtual Colonoscopy

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The Dark Knight

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Does the neccesarily have to remain the domain of radiologist or will gastroenterologist be able to perform and interpert Virtual Colonoscopies?

I don't see why not but there's alot I don't know so I was just curious as to who regulates who can interpert these types of tests. Seems like it would make more senes for the Gastroenterologist to do it so that if there is a poly they can remove it with a scope. Not sure what radiologist would do then..refer them to the gastroenterologist ?

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Does the neccesarily have to remain the domain of radiologist or will gastroenterologist be able to perform and interpert Virtual Colonoscopies?

I don't see why not but there's alot I don't know so I was just curious as to who regulates who can interpert these types of tests. Seems like it would make more senes for the Gastroenterologist to do it so that if there is a poly they can remove it with a scope. Not sure what radiologist would do then..refer them to the gastroenterologist ?

From the rads attendings I've worked with, they expect it to follow the course of a screening mammogram and remain with the radiologist, since it is fundamentally an imaging, screening tool. In any event, VG is a long way away from fully replacing a screening colonoscopy anyway.
 
At the sites that did the studies, both groups read them and there are training courses for interested gastroenterologists. That being said, I have zero interest. I don't believe CT colonography will ever become "like a mammogram" from a compliance perspective. There's nothing virtual about it. The patient gets a bowel prep, has a rectal insufflation tube placed and roles around the CT scanner. How is that better than getting some versed or propofol and waking up in the recovery room? Try getting a patient to come back for their surveillance 5 year CTC. They got suckered by the word "virtual" the first time but not the second.

More problems: The "guidelines" for management of CT colonography findings are completely made up (follow certain size polyps, refer others). There's no evidence that CT colonography decreases the risk of CRC. I see so many patients where CTC was used incorrectly (IDA, adenoma surveillance, etc).

And the dealbreaker for CTC is that CMS agrees with me. The GI societies caved to the radiologists (and invested gastroenterologists, one of whom I work for) and put CTC in their guidelines as an option for CRC screening. CMS, however, has declined to pay for it.
 
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From the rads attendings I've worked with, they expect it to follow the course of a screening mammogram and remain with the radiologist, since it is fundamentally an imaging, screening tool. In any event, VG is a long way away from fully replacing a screening colonoscopy anyway.

Huh Shocker. Perhaps radiology departments around country will create new programs specializing in GI Radiology where they will train them in everything related to GI medicine and allow them to do colonoscopies so that they can essentially be gastroenterologist....... that know how to read a virtual colonoscopy. lol i kid, just stirring up stuff for old times sake but I think our discussion came to a safe place where we had to agree to disagree.


with respect to it being a screening tool, i do find it interesting that we all are now trying to pretend radiation isn't HARMFUL. yes, we've all heard the quotes about radiation through imaging has a small risk but it is much better to take that risk in certain situations to rule out something worse GIVEN the clinical circumstances.

how the heck is it sensible to expose someone to that much radiation from a CT scan at a minimum of every 10 years. What about people who were found to have a precancerous polyp and need a shorter screening interval such as every 3-5 years? Post-cancer patients also are on a shorter screening interval. And the 28 year old that gets diagnosed with UC? He's going to get a dozen CT's before 60? lol.

Yeah if you're pissing blood, or have a 5 month HA with n/v, fever, for god's sake don't worry about the radiation get the CT! But for a screening tool on regular intervals when there's an alternative?? And the alternative allows you to actually remove the polyp if it is found.
 
Huh Shocker. Perhaps radiology departments around country will create new programs specializing in GI Radiology where they will train them in everything related to GI medicine and allow them to do colonoscopies so that they can essentially be gastroenterologist....... that know how to read a virtual colonoscopy. lol i kid, just stirring up stuff for old times sake but I think our discussion came to a safe place where we had to agree to disagree.


with respect to it being a screening tool, i do find it interesting that we all are now trying to pretend radiation isn't HARMFUL. yes, we've all heard the quotes about radiation through imaging has a small risk but it is much better to take that risk in certain situations to rule out something worse GIVEN the clinical circumstances.

how the heck is it sensible to expose someone to that much radiation from a CT scan at a minimum of every 10 years. What about people who were found to have a precancerous polyp and need a shorter screening interval such as every 3-5 years? Post-cancer patients also are on a shorter screening interval. And the 28 year old that gets diagnosed with UC? He's going to get a dozen CT's before 60? lol.

Yeah if you're pissing blood, or have a 5 month HA with n/v, fever, for god's sake don't worry about the radiation get the CT! But for a screening tool on regular intervals when there's an alternative?? And the alternative allows you to actually remove the polyp if it is found.

LOL - don't forget about CT angio too. A 60 year old guy with angina sure would getting a ton of CT scans although I know they use radiation during angio too. Good point though that would be an absurd number of CT scans to do on someone that was found to have precancerous polyps
 
Huh Shocker. Perhaps radiology departments around country will create new programs specializing in GI Radiology where they will train them in everything related to GI medicine and allow them to do colonoscopies so that they can essentially be gastroenterologist....... that know how to read a virtual colonoscopy. lol i kid, just stirring up stuff for old times sake but I think our discussion came to a safe place where we had to agree to disagree.


with respect to it being a screening tool, i do find it interesting that we all are now trying to pretend radiation isn't HARMFUL. yes, we've all heard the quotes about radiation through imaging has a small risk but it is much better to take that risk in certain situations to rule out something worse GIVEN the clinical circumstances.

how the heck is it sensible to expose someone to that much radiation from a CT scan at a minimum of every 10 years. What about people who were found to have a precancerous polyp and need a shorter screening interval such as every 3-5 years? Post-cancer patients also are on a shorter screening interval. And the 28 year old that gets diagnosed with UC? He's going to get a dozen CT's before 60? lol.

Yeah if you're pissing blood, or have a 5 month HA with n/v, fever, for god's sake don't worry about the radiation get the CT! But for a screening tool on regular intervals when there's an alternative?? And the alternative allows you to actually remove the polyp if it is found.

Ha if we pioneered the technique, it's only reasonable we work to keep it in our purview ...and ya, best to let sleeping dogs lie...For the record, I did say VC was a long way away from replacing actual colonoscopies though...for all those reasons and then some :D
 
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Ha if we pioneered the technique, it's only reasonable we work to keep it in our purview ...and ya, best to let sleeping dogs lie...For the record, I did say VC was a long way away from replacing actual colonoscopies though...for all those reasons and then some :D

How did you find your way over here on the GI board ? LOL. you must have a way of tracking all posts related to radiology.

again have to disagree. im not disagreeing with the fact that CTC was developed by radiologist but again it's a tool that plays a part in a much bigger picture and that is the overall GI health of the patient. If gastroenterologist can read the studies via appropriate training then it would make more sense for them to perform it no? They won't need to know how to interpert a head or chest CT, just one single test. I think we need radiologist and i think they train hard and earn the money they get but there are certain areas where it just makes sense to have the medicine doctor who is an expert in the anatomy and pathology of an organ system learn to read the imaging themselves

Still at the end of the day it is absurd to use CT scans for screening tools. Screening does not equal Diagnosing. At some point it's destined to be bad news if you have yourself a 72 yo women who's been getting her regular mamograms, 3 CTs (50, 60, 70) and hell maybe she had some exertional chest pain that required her to get a minimally invasive CT angio...ughhh. i know some people like to down play the risk of cancer with radiation exposure but there has to be a limit.
 
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I can't believe that nobody has raised the obvious problem with non-radiologists reading VC's -- it's the extra-colonic stuff!

Reading a VC isn't that hard. Anybody can do that. Learning how to catch the lung, liver, splenic, renal, adrenal, pancreatic, vascular, etc pathologies is the really difficult part. There's so much that goes in the abdomen that you need to have as much training as a radiologist to read such studies correctly. From the studies I've read, 15% or more of VC's have extra-colonic findings that require additional work-up. That's nothing to sneeze at when a lawyer will be breathing down your back for missing that liver tumor. Even radiologists who don't read a lot of body CT's for a living have a hard time reading them.

There's a reason why you never really hear about any group wanting to try to steal CT chest, abdomen, and pelvis from radiologists. It's because it's like a minefield of litigation waiting to blow up in your face. It's why the cardiologists are having a hard time trying to own cardiac CT's -- because of the lung fields. The vast majority of the cancers and diseases originate in the chest, abdomen, or pelvis.

IMHO, I think what will happen is that VC will be added on as a service to outpatient radiology like mammo, bone density, and pretty soon CT lung screenings. I also don't see why the radiologist not only reads the VC but also does the c-scopes themselves. With VC, the radiologist would have a roadmap. Of course, that is heresy talk but I think that you'll eventually see that. VC is getting closer to Medicare reimbursement. I think within 5 years. Remember that the President of the United States opted for a VC. Anyways, that's my two cents.
 
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Here's a good article:

CTC Use Grows Despite Reimbursement Obstacles

Although CT colonography (CTC), or virtual colonoscopy, has yet to be approved as a screening tool by the Centers for Medicare & Medicaid Services (CMS), new research shows the technique is growing in popularity and expanding its reimbursement numbers.

A study in the March issue of Journal of the American College of Radiology (JACR) revealed that the percent of U.S. hospitals offering CTC grew from 13 to 17 between 2005 and 2008. Also in that time span, nationwide use of diagnostic CTC Medicare fee-for-service beneficiaries tripled and fewer CTC claims have been denied, according to a study published in the April issue of JACR. The April study shows that the total annual claims for diagnostic CTC for Medicare fee-for-service beneficiaries climbed from 3,660 to 10,802, or 195 percent, between 2005 and 2008, the first four complete years for which Current Procedural Terminology (CPT) tracking codes existed, according to study co-author Perry Pickhardt, M.D., a professor of radiology at the University of Wisconsin School of Medicine and Public Health in Madison.

Dr. Pickhardt's study also showed that the annual national denial rate decreased from 70 percent in 2005 to 43.4 percent in 2008.

...

"CT colonography has passed every litmus test conceivable," he said. "Within five years, it should be a—if not the—frontline screening test for colorectal cancer."​
 
I also don't see why the radiologist not only reads the VC but also does the c-scopes themselves. With VC, the radiologist would have a roadmap.

I don't think anybody has to worry about Rad guys doing C-scopes for many reasons...as far as VC, the problem is that if you do find something, which you will in the large majority of the older population, even if at the end it turns out to be a hyperplastic polyp, you still have to end up getting the C-scope, furthermore VC's ability to catch flat polyps is very questionable, also the most unpleasant part of the whole process is the prep portion which you have to do for both C-scope and VC, so why anybody would choose VC over C-scope is beyond me.
 
VC's would be beneficial to both rads, gi and ultimately the patient. Many patients are afraid of having something put up there rear end. How many patients don't their screening colonoscopy because of this? 30%? So a VC would allow them to still get their screening. Then if they do find a suspicious lesion, they could have the intervention performed by the gi docs. So basically you get to tap into a new market for both radiologists and GI docs. The therapeutic colonoscopy is better reimbursed as well.
 
VC's would be beneficial to both rads, gi and ultimately the patient. Many patients are afraid of having something put up there rear end. How many patients don't their screening colonoscopy because of this? 30%? So a VC would allow them to still get their screening. Then if they do find a suspicious lesion, they could have the intervention performed by the gi docs. So basically you get to tap into a new market for both radiologists and GI docs. The therapeutic colonoscopy is better reimbursed as well.

During my rads rotation, one of the attendings mentioned pretty much what you said, he didn't give a percentage of patients neglecting their colonscopy though. He also mentioned that he expects many patients who get a VC to see a GI anyways due to "suspicious lesions."
 
This thread is classic. Radiologists doing colonoscopy. CTC sold as "people don't want things put up their butt" when they have air insufflated via a rectal catheter awake vice being sedated for a colonoscopy. Data from 2008 that showed the use of CTC was increasing (WHICH WAS BEFORE THE CMS DECISION). I'm not sure which part is more laughable.

The idea that a patient gets a CTC, waits around, the scan gets read and then for abnormals, the patient is offered a same day colo sounds great. Until you consider how incredibly inconvenient it is for the radiologist and gastroenterologist plus all the nurses and techs you pay to keep a room ready for that purpose. This model only works in places that don't care about profit and have doctors they can abuse (trainees).

Most insurance companies don't pay for CTC. The data presented at DDW this year showed that people who have had a CTC are less likely to come back for repeat studies than people who had colonoscopy. Incidentaloma chasing sucks.

The real threat to screening colonoscopy is better stool tests.
 
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This thread is classic. Radiologists doing colonoscopy. CTC sold as "people don't want things put up their butt" when they have air insufflated via a rectal catheter awake vice being sedated for a colonoscopy. Data from 2008 that showed the use of CTC was increasing (WHICH WAS BEFORE THE CMS DECISION). I'm not sure which part is more laughable.

The idea that a patient gets a CTC, waits around, the scan gets read and then for abnormals, the patient is offered a same day colo sounds great. Until you consider how incredibly inconvenient it is for the radiologist and gastroenterologist plus all the nurses and techs you pay to keep a room ready for that purpose. This model only works in places that don't care about profit and have doctors they can abuse (trainees).

Most insurance companies don't pay for CTC. The data presented at DDW this year showed that people who have had a CTC are less likely to come back for repeat studies than people who had colonoscopy. Incidentaloma chasing sucks.

The real threat to screening colonoscopy is better stool tests.

Now, potentially no laxatives required. Discuss.

http://blogs.wsj.com/health/2012/05/14/new-method-easing-preparation-may-encourage-colon-checks/
 
Felt the need to bump this thread after USPTF approval of VC for screening purposes. Looks like Taurus was almost oracle-like in predicting the decision. What's the consensus from GI? Is this a battle we'll be losing/already lost?
 
A stool test will replace both techniques eventually. It is just a matter of time.

- Screening test does not need to be 100% accurate. If a stool test is even 80-85%% accurate, it will replace both techniques. Mammo is only 70% accurate but has not been replaced by breast MRI which is 95%+ accurate.

- Screening test should be CHEAP, AVAILABLE and with minimal RISK.

-We live in a time that the government is trying aggressively to decrease the costs. Recent USPTF decision is based on MONEY and not necessarily SCIENCE. Its main goal is not to approve CTC. Its main goal is to phase out screening colonoscopy and later screening CTC gradually and replacing them with a stool test. In summary, government says that it is not willing to spend that much money on screening for colon cancer.

- Even if the accuracy of CTC is 10-15% less than colonoscopy, just the fact that medicare pays for it means some of the colonoscopy business will go towards it.

- For those who talk about radiation, don't forget that CMS pays for barium enema. It is funny that they didn't pay for CTC but paid for barium enema. It is another strong evidence that the decision of USPTF is based on money and not science.
 
This thread is classic. Radiologists doing colonoscopy. CTC sold as "people don't want things put up their butt" when they have air insufflated via a rectal catheter awake vice being sedated for a colonoscopy. Data from 2008 that showed the use of CTC was increasing (WHICH WAS BEFORE THE CMS DECISION). I'm not sure which part is more laughable.

The idea that a patient gets a CTC, waits around, the scan gets read and then for abnormals, the patient is offered a same day colo sounds great. Until you consider how incredibly inconvenient it is for the radiologist and gastroenterologist plus all the nurses and techs you pay to keep a room ready for that purpose. This model only works in places that don't care about profit and have doctors they can abuse (trainees).

Most insurance companies don't pay for CTC. The data presented at DDW this year showed that people who have had a CTC are less likely to come back for repeat studies than people who had colonoscopy. Incidentaloma chasing sucks.

The real threat to screening colonoscopy is better stool tests.

Turns out Taurus is right. 5 years later like he predicted.
 
I don't think anybody has to worry about Rad guys doing C-scopes for many reasons...as far as VC, the problem is that if you do find something, which you will in the large majority of the older population, even if at the end it turns out to be a hyperplastic polyp, you still have to end up getting the C-scope, furthermore VC's ability to catch flat polyps is very questionable, also the most unpleasant part of the whole process is the prep portion which you have to do for both C-scope and VC, so why anybody would choose VC over C-scope is beyond me.

Turns out he was right
 
Isn't this great for GI? More people being screened = greater proportion of colonoscopies with polypectomy (which pay more than those without)
 
Isn't this great for GI? More people being screened = greater proportion of colonoscopies with polypectomy (which pay more than those without)

No, I don't think so. This is how I envision things playing out. As many people have alluded to, stool studies could become more and more popular in the future, especially if the sensitivity and specificity are 90+%. When the stool study returns positive, then the next logical step is imaging. If you are pretty sure that the person has colon cancer, then you want to know where the cancer may be located at, if it is causing obstruction, if there are local enlarged metastatic nodes, if there are distant mets to the liver, bones, etc. Imaging answers lots of these questions. As VC becomes more common, I think that even GI will want to know these before sticking a scope into a person. That's what you see in other areas of medicine. It doesn't make sense to scope or do surgery on someone until you first do non-invasive imaging. It's fairly common for GI's to order MRCP before they do ERCP. I see a similar trajectory.

The net result is that I think screening traditional colonoscopies have peaked. Diagnostic colonoscopies to get tissue sample makes more sense and will be the predominant form of colonoscopies in the future I believe. The problem for GI is that the total number of colonoscopies will decrease by a lot if you take away most screening traditional colonoscopies.

For radiology, this is still a net positive because this is a brand new area of growth for the field. If they invent a stool tag that eliminates the bowel prep and colon insufflation that is used currently, then VC will definitely take off.
 
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No, I don't think so. This is how I envision things playing out. As many people have alluded to, stool studies could become more and more popular in the future, especially if the sensitivity and specificity are 90+%. When the stool study returns positive, then the next logical step is imaging. If you are pretty sure that the person has colon cancer, then you want to know where the cancer may be located at, if it is causing obstruction, if there are local enlarged metastatic nodes, if there are distant mets to the liver, bones, etc. Imaging answers lots of these questions. As VC becomes more common, I think that even GI will want to know these before sticking a scope into a person. That's what you see in other areas of medicine. It doesn't make sense to scope or do surgery on someone until you first do non-invasive imaging. It's fairly common for GI's to order MRCP before they do ERCP. I see a similar trajectory.

The net result is that I think screening traditional colonoscopies have peaked. Diagnostic colonoscopies to get tissue sample makes more sense and will be the predominant form of colonoscopies in the future I believe. The problem for GI is that the total number of colonoscopies will decrease by a lot if you take away most screening traditional colonoscopies.

For radiology, this is still a net positive because this is a brand new area of growth for the field. If they invent a stool tag that eliminates the bowel prep and colon insufflation that is used currently, then VC will definitely take off.

Hmm interesting. I know from a colleague in Australia that they actually have fecal occult blood testing as their screening tool. But anyone who turns up a positive stool result ends up getting a colonoscopy. And they are so swamped with colonoscopy waiting times that they're starting up massive nurse endoscopist training programs to cover the load.

Will be interesting to see how it plays out.
 
And they are so swamped with colonoscopy waiting times that they're starting up massive nurse endoscopist training programs to cover the load.

That's exactly my point. If family docs and nurses are doing colonoscopies, then it's crazy to think that radiologists can't do them either. We already do a ton of invasive procedures. Colonoscopies won't be hard for us to pick up. As I mentioned before, if radiology discovers the lesion as part of screening VC at their imaging center, it's their discretion whether to refer the patient out to another specialty to do the colonoscopy. This is radiology's version of owning the patient. If they have the setup and expertise, the radiologist could do the colonoscopy himself. This probably won't happen for 10-20 years but it's inevitable. Look at mammo as an example. Radiologist sees the breast mass and performs the biopsy. Surgeon only knows about the breast cancer after path comes back.
 
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That's exactly my point. If family docs and nurses are doing colonoscopies, then it's crazy to think that radiologists can't do them either. We already do a ton of invasive procedures. Colonoscopies won't be hard for us to pick up. As I mentioned before, if radiology discovers the lesion as part of screening VC at their imaging center, it's their discretion whether to refer the patient out to another specialty to do the colonoscopy. This is radiology's version of owning the patient. If they have the setup and expertise, the radiologist could do the colonoscopy himself. This probably won't happen for 10-20 years but it's inevitable. Look at mammo as an example. Radiologist sees the breast mass and performs the biopsy. Surgeon only knows about the breast cancer after path comes back.

Who will train these radiologists to do colonoscopies?
 
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Who will train these radiologists to do colonoscopies?

Who trained the nephrologists or neurologists to do interventional work? It starts somewhere. Either you pay somebody a boatload of $$$ to train you or perhaps cross training at some academic center. Once one radiologist is trained, the genie is out of the bottle. It's a question of when and not if it will come to be reality. First, several more years just to hammer out the reimbursement and set up programs throughout the country.
 
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