DOI:10.2214/AJR.06.5086
AJR 2006; 187:W661
© American Roentgen Ray Society
Utilization of the Double-Contrast Barium Enema in the Early Era of Screening CT Colonography
Perry J. Pickhardt
University of Wisconsin Medical School Madison, WI
53792-3252
WEB—This is a Web exclusive article.
I read with interest the article by Dr. Ferrucci in the July 2006 issue of
the AJR [1], in which
he details the recent use of the double-contrast barium enema (DCBE) at his
institution over a 4-year period. As might be expected, he found that DCBE was
a low-yield procedure for detecting polyps, with a high false-positive rate
and dwindling overall volume. Dr. Ferrucci, whom I generally regard as the
"virtual godfather" of CT colonography (CTC) for his pivotal role
in its development, makes a cogent argument that CTC should replace the DCBE
on approved national colon screening guidelines. At this point in time, it
seems almost unconscionable that validated CTC screening methods remain
largely uncovered by national third-party payers, whereas the DCBE remains
widely reimbursed yet largely ineffective
[2,
3]. Indeed, the persistence of
the anachronistic DCBE and absence of CTC on current screening guidelines seem
to reflect the political nature of such decisions and the strange times in
which we live.
At the University of Wisconsin Hospital and Clinics (UWHC), we have enjoyed
third-party reimbursement for CTC screening since April 2004, as a result of
previous validation of our methodology
[4,
5]. Dr. Ferrucci's interesting
work has motivated me to look at our utilization of the DCBE at UWHC. In many
ways, this represents a glimpse into the potential future of national practice
patterns—that is, once CTC screening ultimately gains universal
coverage.
Over a 26-month interval beginning in April 2004 (when coverage for CTC
screening was initiated at UWHC), we performed a total of 424 contrast enema
examinations. Of these, only 33 studies (7.8%) were performed using the
double-contrast technique. Of particular interest, only one of these studies
(0.2%) was performed for the purpose of screening, in conjunction with
flexible sigmoidoscopy in a 49-year-old man. The remaining DCBE studies were
performed either in symptomatic patients (n = 18), of whom 10 were 30
years old or younger, or patients after having undergone incomplete optical
colonoscopy (n = 14). In comparison, over the same period of time we
performed well over 3,000 CTC examinations at UWHC. CTC was performed for
incomplete optical colonoscopy in 173 patients, but most of the remaining
examinations were performed for screening asymptomatic patients.
Overall, the performance results of CTC screening in this real-world
setting have surpassed what we had expected on the basis of the results with
this method from an earlier multicenter screening trial
[5,
6]. The reason for DCBE instead
of CTC evaluation for a minority (7.5%; 14/187) of patients with incomplete
colonoscopy was primarily due to the fact that our local coverage
determination (LCD) for Medicare lagged behind local managed care coverage and
initially was too restrictive.
The immediate impact of third-party payer coverage for screening CTC on
practice patterns at our institution is clear. In short, since April 2004,
there has no longer been a viable indication to perform DCBE for examination
of our patient population. I suspect the same fate ultimately awaits the DCBE
at the national level once widespread coverage for CTC screening is in place.
However, given the fact that most of the sites (12 of 15) involved in the
ongoing ACRIN (American College of Radiology Imaging Network) Trial are
utilizing a CTC system largely based on primary 2D polyp detection, which has
not fared well in previous studies compared with a primary 3D approach, we may
be in for a bumpy ride in the near term.
References
- Ferrucci JT. Double-contrast barium enema: use in practice and
implications for CT colonography. AJR2006; 187:170
-173[Abstract/Free Full Text]
- Winawer SJ, Stewart ET, Zauber AG, et al. A comparison of
colonoscopy and double-contrast barium enema for surveillance after
polypectomy. N Engl J Med 2000;342
: 1766-1772[Abstract/Free Full Text]
- Rockey DC, Paulsen EK, Niedzwiecki D, et al. Analysis of air
contrast barium enema, computed tomographic colonography, and colonoscopy:
prospective comparison. Lancet 2005;365
: 305-311[Medline]
- Barnes E. HMO pays for screening virtual
colonoscopy. Available at:
www.auntminnie.com.
Accessed June 4, 2004
- Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual
colonoscopy to screen for colorectal neoplasia in asymptomatic adults.
N Engl J Med 2003;349
: 2191-2200[Abstract/Free Full Text]
- Pickhardt PJ, Taylor AJ, Kim DH, Reichelderfer M, Gopal DV, Pfau
PR. Screening for colorectal neoplasia with CT colonography: initial
experience from the first year of coverage by third-party payers.
Radiology 2006 Sep 18; [Epub ahead of
print]
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