Trends in Adenoma Detection Rates During the First 10 Years of the German Screening Colonoscopy Program

      Background & Aims

      The adenoma detection rate (ADR) is an important quality indicator of screening colonoscopy; it is inversely associated with risk of interval cancers and colorectal cancer mortality. We assessed trends in the ADR in the first 10 years of the German screening colonoscopy program.


      We calculated age-adjusted and age-specific detection rates of nonadvanced adenomas and advanced adenomas for each calendar year based on 4.4 million screening colonoscopies conducted from 2003 through 2012 and reported to the German screening colonoscopy registry.


      We observed a steady and strong increase in rate of detection of nonadvanced adenomas in both sexes and all age groups. Age-adjusted rates of detection of nonadvanced adenomas increased from 13.3% to 22.3% among men and from 8.4% to 14.9% among women. This increase was mostly due to an increase in detection rates of adenomas <0.5 cm, and it is partly explained by an innovation effect (higher ADRs among incoming colonoscopists than among leaving colonoscopists, and relatively stable ADRs among continuing colonoscopists). Only modest increases were observed in detection rates of advanced adenomas (from 7.4% to 9.0% among men, and from 4.4% to 5.2% among women) and colorectal cancer. In 2012, overall ADR reached 31.3% and 20.1% in men and women, respectively.


      We observed a strong increase in ADRs from 2003 through 2012 in Germany. Although we cannot exclude the effects of secular trends in colorectal neoplasm prevalence, the observed increase was mainly the result of a steady increase in detection of nonadvanced adenomas (especially adenomas <0.5 cm). Further research should address potential implications for defining screening and surveillance intervals.


      Abbreviations used in this paper:

      ADR (adenoma detection rate), CRC (colorectal cancer)
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        • Zauber A.G.
        • Winawer S.J.
        • O’Brien M.J.
        • et al.
        Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.
        N Engl J Med. 2012; 366: 687-696
        • Doubeni C.A.
        • Weinman S.
        • Adams K.
        • et al.
        Screening colonoscopy and risk for incident late-stage colorectal cancer diagnosis in average-risk adults.
        Ann Intern Med. 2013; 158: 312-320
        • Brenner H.
        • Chang-Claude J.
        • Jansen L.
        • et al.
        Reduced risk of colorectal cancer up to 10 years after screening, surveillance or diagnostic colonoscopy.
        Gastroenterology. 2014; 146: 709-717
        • Nishihara R.
        • Wu K.
        • Lochhead P.
        • et al.
        Long-term colorectal-cancer incidence and mortality after lower endoscopy.
        N Engl J Med. 2013; 369: 1095-1105
        • Brenner H.
        • Stock C.
        • Hoffmeister M.
        Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies.
        BMJ. 2014; 348: g2467
        • Peters S.L.
        • Hasan A.G.
        • Jacobson N.B.
        • et al.
        Level of fellowship training increases adenoma detection rates.
        Clin Gastroenterol Hepatol. 2010; 8: 439-442
        • Wang H.S.
        • Pisegna J.
        • Modi R.
        • et al.
        Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance.
        Gastrointest Endosc. 2013; 77: 71-78
        • Calderwood A.H.
        • Jacobson B.C.
        Colonoscopy quality: metrics and implementation.
        Gastroenterol Clin North Am. 2013; 42: 599-618
        • Kaminski M.F.
        • Regula J.
        • Kraszewska E.
        • et al.
        Quality indicators for colonoscopy and the risk of interval cancer.
        N Engl J Med. 2010; 362: 1795-1803
        • Corley D.A.
        • Jensen C.D.
        • Marks A.R.
        • et al.
        Adenoma detection rate and risk of colorectal cancer and death.
        N Engl J Med. 2014; 370: 1298-1306
        • Regula J.
        • Rupinski M.
        • Kraszewska E.
        • et al.
        Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia.
        N Engl J Med. 2006; 355: 1863-1872
        • Brenner H.
        • Altenhofen L.
        • Hoffmeister M.
        Sex, age and birth cohort effects in colorectal neoplasms: a cohort analysis.
        Ann Intern Med. 2010; 102: 1411-1414
        • Ferlitsch M.
        • Reinhart K.
        • Pramhas S.
        • et al.
        Sex-specific prevalence of adenomas, advanced adenomas, and colorectal cancer in individuals undergoing screening colonoscopy.
        JAMA. 2011; 306: 1352-1358
        • Pox C.
        • Altenhofen L.
        • Brenner H.
        • et al.
        Efficacy of a nationwide screening colonoscopy program for colorectal cancer.
        Gastroenterology. 2012; 142: 1460-1467
        • Ricci E.
        • Hassan C.
        • Petruzziello L.
        • et al.
        Inter-centre variability of the adenoma detection rate: a prospective, multicentre study.
        Dig Liver Dis. 2013; 45: 1022-1027
        • Adler A.
        • Lieberman D.
        • Aminalai A.
        • et al.
        Data quality of the German screening colonoscopy registry.
        Endoscopy. 2013; 45: 813-818
        • Adler A.
        • Wegscheider K.
        • Lieberman D.
        • et al.
        Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12,134 examinations (Berlin colonoscopy project 3, BECOP-3).
        Gut. 2013; 62: 236-241
        • Jover R.
        • Zapater P.
        • Polania E.
        • et al.
        Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies.
        Gastrointest Endosc. 2013; 77: 381-389
        • Rex D.K.
        • Petrini J.L.
        • Baron T.H.
        • et al.
        Quality indicators for colonoscopy.
        Gastrointest Endosc. 2006; 63: S16-S28
        • Lieberman D.
        • Nadel M.
        • Smith R.A.
        • et al.
        Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable.
        Gastrointest Endosc. 2007; 65: 757-766
      1. KBV Qualitätsbericht Ausgabe 2013 [in German]. Available at:$FILE/KBV_QualBericht_2013.pdf. Accessed December 19, 2014.

        • Van Rijn J.C.
        • Reitsma J.B.
        • Stoker J.
        • et al.
        Polyp miss rate determined by tandem colonoscopy: a systematic review.
        Am J Gastroenterol. 2006; 101: 343-350
        • Rex D.K.
        • Bond J.H.
        • Winawer S.
        • et al.
        Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer.
        Am J Gastroenterol. 2002; 97: 1296-1308
        • Pohl H.
        • Robertson D.J.
        Colorectal cancers detected after colonoscopy frequently result from missed lesions.
        Clin Gastroenterol Hepatol. 2010; 8: 858-864
        • Brenner H.
        • Chang-Claude J.
        • Seiler C.M.
        • et al.
        Interval cancers after negative colonoscopy: population-based case-control study.
        Gut. 2012; 61: 1576-1582
      2. Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): S3-Leitlinie Kolorektales Karzinom, Langversion 1.0, AWMF Registrierungsnummer: 021-0070L. Available at: Accessed October 11, 2014.

        • Lieberman D.A.
        • Rex D.K.
        • Winawer S.J.
        • et al.
        Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2012; 143: 844-857
        • Dik V.K.
        • Moons L.M.
        • Siersema P.D.
        Endoscopic innovations to increase the adenoma detection rate during colonoscopy.
        World J Gastroenterol. 2014; 20: 2200-2211
        • Gómez V.
        • Wallace M.B.
        Advances in diagnostic and therapeutic colonoscopy.
        Curr Opin Gastroenterol. 2014; 30: 63-68
        • Gralnek I.M.
        • Sieresma P.D.
        • Halpern Z.
        • et al.
        Standard forward-viewing colonoscopy versus full-spectrum endoscopy: an international, multicenter, randomised tandem colonoscopy trial.
        Lancet Oncol. 2014; 15: 353-360
        • Lansdorp-Vogelaar I.
        • Knudsen A.
        • Brenner H.
        Cost-effectiveness of colorectal cancer screening.
        Epidemiol Rev. 2011; 33: 88-100
        • Greenspan M.
        • Rajan K.B.
        • Baig A.
        • et al.
        Advanced adenoma detection rate is independent of nonadvanced adenoma detection rate.
        Am J Gastroenterol. 2013; 108: 1286-1292
        • Stock C.
        • Uhlmann L.
        • Hoffmeister M.
        • et al.
        Identification of physicians with unusual performance in screening colonoscopy databases: a Bayesian approach.
        Gastrointest Endosc. 2015; 81: 646-654.e1