Colorectal cancer prevention by a CLEAR principles–based colonoscopy protocol: an observational study

Sudha Xirasagar, Yuqi Wu, Meng han Tsai, Jiajia Zhang, Stephanie Chiodini, Piet C. de Groen

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Background and Aims: Colorectal cancer (CRC) prevention by colonoscopy has been lower than expected. We studied CRC prevention outcomes of a colonoscopy protocol based on Clean the colon, Look Everywhere, and complete Abnormality Removal (CLEAR) principles. Methods: This observational follow-up study studied patients provided screening colonoscopy at a free-standing private ambulatory surgery center in South Carolina by 80 endoscopists from October 2001 to December 2014, followed through December 2015. The colonoscopy protocol, optimized for polyp clearance, featured in-person bowel preparation instructions reinforced by phone, polyp search and removal throughout insertion and gradual withdrawal with circumferential tip movements, and a team approach using all personnel present to maximize polyp detection, patient safety, and clear-margin polypectomy including requesting repeat inspection or additional tissue removal. Outcome measures were postscreening lifetime CRC risk relative to Surveillance Epidemiology and End Results (SEER)-18 and interval cancer rate (postcolonoscopy CRCs among cancer-free patients at screening). Results: Of 25,862 patients (mean age, 58.1 years; 52% black; 205,522 person-years of observation), 159 had CRC at screening and 67 patients developed interval CRC. The interval CRC rate was 3.34 per 10,000 person-years of observation, 5.79 and 2.24 among patients with and without adenomas, respectively. The rate was similar among older patients (mean age 68.5 years at screening) and with prolonged follow-up. Postscreening lifetime CRC risk was 1.6% (bootstrap 95% confidence interval, 1.3%-1.8%) versus 4.7% in SEER-18, 67% lower. Subgroups with mean screening ages of 50 and 68.5 years showed risk reductions of 80% and 72%, respectively. The adverse event rate was less than usually reported rates: perforation 2.6 per 10,000, bleeding with hospitalization 2.4 per 10,000, and no deaths. Conclusions: A colonoscopy protocol optimized for polyp clearance prevented 67% of CRC compared with a SEER-18 population given ongoing population screening.

Original languageEnglish (US)
Pages (from-to)905-916.e4
JournalGastrointestinal endoscopy
Issue number4
StatePublished - Apr 2020

Bibliographical note

Funding Information:
DISCLOSURE: The following authors received research support for this study from the National Institutes of Health: S. Xirasagar, P. de Groen (grants 1R21CA202477 and 3R21CA202477-01S1); P. de Groen (grant R01DK106130) and the University of Minnesota. The funding organization had no role in study planning, interpretation of findings, manuscript preparation, or journal submission. All other authors disclosed no financial relationships.

Publisher Copyright:
© 2020 American Society for Gastrointestinal Endoscopy


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