Skip to main content


Log in

Overuse of Colonoscopy for Colorectal Cancer Screening and Surveillance

  • Original Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript



Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources.


Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse.


Our approach was a retrospective cohort study using electronic health record data for patients 50–65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice.


We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies.


We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88 %) and many surveillance colonoscopies (49 %) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1–10.0; hyperplastic polyp: 5.7 years, IQR: 4.9–9.7; low-risk adenoma: 5.1 years, IQR: 3.3–6.3; high-risk adenoma: 2.9 years, IQR: 2.0–3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95 % CI: 3.15–12.50) and surveillance colonoscopy (OR 13.47, 95 % CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam.


Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Figure 1.

Similar content being viewed by others


  1. Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366(8):687–696.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  2. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008;134(5):1570–1595.

    Article  CAS  PubMed  Google Scholar 

  3. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997;112(2):594–642.

    Article  CAS  PubMed  Google Scholar 

  4. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003;124(2):544–560.

    Article  PubMed  Google Scholar 

  5. Winawer SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology. 2006;130(6):1872–1885.

    Article  PubMed  Google Scholar 

  6. Preventive Services US. Task Force. Screening for colorectal cancer: recommendation and rationale. Ann Intern Med. 2002;137(2):129–131.

    Article  Google Scholar 

  7. Preventive Services US. Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(9):627–637.

    Article  Google Scholar 

  8. Centers for Disease Control and Prevention. Vital signs: Colorectal cancer screening, incidence, and mortality--United States, 2002-2010. Morb Mortal Wkly Rep. 2011; 60(26):884-889.

  9. Massachusetts Healthcare Quality Partners. Quality Insights: Clinical Quality in Primary Care 2012., 100770, 100771, 100785, 100791, 100794, 100822, 100899, 100834, 101010, 100857, 100863, 100866, 100875, 100891, 100892, 100893&MeasureID = 26. Accessed August 19, 2014.

  10. Menees SB, Elliott E, Govani S, Anastassiades C, Schoenfeld P. Adherence to recommended intervals for surveillance colonoscopy in average-risk patients with 1 to 2 small (<1 cm) polyps on screening colonoscopy. Gastrointest Endosc. 2014;79(4):551–557.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Cooper GS, Kou TD, Barnholtz Sloan JS, Koroukian SM, Schluchter MD. Use of colonoscopy for polyp surveillance in Medicare beneficiaries. Cancer. 2013;119(10):1800–1807.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Saini SD, Vijan S, Schoenfeld P, Powell AA, Moser S, Kerr EA. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ. 2014;348:g1247.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Goodwin JS, Singh A, Reddy N, Riall TS, Kuo YF. Overuse of screening colonoscopy in the Medicare population. Arch Intern Med. 2011;171(15):1335–1343.

    Article  PubMed  Google Scholar 

  14. Schoen RE, Pinsky PF, Weissfeld JL, et al. Utilization of surveillance colonoscopy in community practice. Gastroenterology. 2010;138(1):73–81.

    Article  PubMed Central  PubMed  Google Scholar 

  15. Mysliwiec PA, Brown ML, Klabunde CN, Ransohoff DF. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med. 2004;141(4):264–271.

    Article  PubMed  Google Scholar 

  16. Boolchand V, Olds G, Singh J, Singh P, Chak A, Cooper GS. Colorectal screening after polypectomy: a national survey study of primary care physicians. Ann Intern Med. 2006;145(9):654–659.

    Article  PubMed  Google Scholar 

  17. Krist AH, Jones RM, Woolf SH, et al. Timing of repeat colonoscopy: disparity between guidelines and endoscopists' recommendation. Am J Prev Med. 2007;33(6):471–478.

    Article  PubMed  Google Scholar 

  18. Robertson RH, Burkhardt JH, Powell MP, Eloubeidi MA, Pisu M, Weissman NW. Trends in colon cancer screening procedures in the US Medicare and Tricare populations: 1999-2001. Prev Med. 2006;42(6):460–462.

    Article  PubMed  Google Scholar 

  19. Laiyemo AO, Doubeni C, Sanderson AK, et al. Likelihood of missed and recurrent adenomas in the proximal versus the distal colon. Gastrointest Endosc. 2011;74(2):253–261.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Holden DJ, Jonas DE, Porterfield DS, Reuland D, Harris R. Systematic review: enhancing the use and quality of colorectal cancer screening. Ann Intern Med. 2010;152(10):668–676.

    Article  PubMed  Google Scholar 

  21. American Board of Internal Medicine Foundation. Choosing Wisely. 2013; Accessed August 19, 2014.

  22. Sequist TD, Zaslavsky AM, Marshall R, Fletcher RH, Ayanian JZ. Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial. Arch Intern Med. 2009;169(4):364–371.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Corley DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370(14):1298–1306.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  24. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2006;101(4):873–885.

    Article  PubMed  Google Scholar 

  25. Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143(3):844–857.

    Article  PubMed  Google Scholar 

  26. Murff HJ, Greevy RA, Syngal S. The comprehensiveness of family cancer history assessments in primary care. Community Genet. 2007;10(3):174–180.

    Article  PubMed  Google Scholar 

  27. Snijders TAB, Bosker RJ. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. London: Sage; 1999.

    Google Scholar 

  28. Sheffield KM, Han Y, Kuo YF, Riall TS, Goodwin JS. Potentially inappropriate screening colonoscopy in Medicare patients: variation by physician and geographic region. JAMA Intern Med. 2013;173(7):542–550.

    Article  PubMed  Google Scholar 

  29. Klabunde CN, Frame PS, Meadow A, Jones E, Nadel M, Vernon SW. A national survey of primary care physicians' colorectal cancer screening recommendations and practices. Prev Med. 2003;36(3):352–362.

    Article  PubMed  Google Scholar 

  30. Yabroff KR, Klabunde CN, Yuan G, et al. Are physicians' recommendations for colorectal cancer screening guideline-consistent? J Gen Intern Med. 2011;26(2):177–184.

    Article  PubMed Central  PubMed  Google Scholar 

  31. Saini SD, Nayak RS, Kuhn L, Schoenfeld P. Why don't gastroenterologists follow colon polyp surveillance guidelines?: results of a national survey. J Clin Gastroenterol. 2009;43(6):554–558.

    Article  PubMed  Google Scholar 

  32. Larsen M, Hills N, Terdiman J. The impact of the quality of colon preparation on follow-up colonoscopy recommendations. Am J Gastroenterol. 2011;106(12):2058–2062.

    Article  PubMed  Google Scholar 

  33. Murff HJ, Peterson NB, Greevy RA, Shrubsole MJ, Zheng W. Early initiation of colorectal cancer screening in individuals with affected first-degree relatives. J Gen Intern Med. 2007;22(1):121–126.

    Article  PubMed Central  PubMed  Google Scholar 

  34. Murray MF, Giovanni MA, Klinger E, et al. Comparing Electronic Health Record Portals to Obtain Patient-Entered Family Health History in Primary Care. J Gen Intern Med. 2013.

  35. Schenck AP, Klabunde CN, Warren JL, et al. Data sources for measuring colorectal endoscopy use among Medicare enrollees. Cancer Epidemiol Biomarkers Prev. 2007;16(10):2118–2127.

    Article  PubMed  Google Scholar 

  36. Joseph DA, King JB, Miller JW, Richardson LC. Centers for Disease Control and Prevention. Prevalence of colorectal cancer screening among adults–Behavioral Risk Factor Surveillance System, United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(Suppl):51–56.

    PubMed  Google Scholar 

  37. Mitka M. Colorectal cancer screening rates still fall far short of recommended levels. JAMA. 2008;299(6):622.

    Article  CAS  PubMed  Google Scholar 

  38. Slomski A. Expert panel offers advice to improve screening rates for colorectal cancer. JAMA. 2010;303(14):1356–1357.

    Article  CAS  PubMed  Google Scholar 

  39. Consumer Reports. Consumer Reports Health "What's Fair?" Fair healthcare pricing from Healthcare Blue Book: Colonoscopy. 2012; Accessed August 19, 2014.

  40. Seeff LC, Richards TB, Shapiro JA, et al. How many endoscopies are performed for colorectal cancer screening? Results from CDC's survey of endoscopic capacity. Gastroenterology. 2004;127(6):1670–1677.

    Article  PubMed  Google Scholar 

  41. U.S. Census Bureau. Current Population Survey, Annual Social and Economic Supplement. 2011; Accessed August 19, 2014.

Download references


We would like to thank Craig Salman (Harvard Vanguard Medical Associates and Atrius Health) for his assistance with data management and analysis, Amy Marston (Harvard Vanguard Medical Associates and Atrius Health) for her project management, and Debby Collins (Department of Health Care Policy, Harvard Medical School) for project coordination.

Dr. Kruse had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

The study was supported by the National Cancer Institute R01 CA112367. Dr. Kruse was supported by Health Resources and Services Administration training grant T32HP12706, the Ryoichi Sasakawa Fellowship Fund, and the National Cancer Institute 5R25 CA057711-20.

An earlier version of the manuscript was accepted for presentation at the Annual Meeting of the Society for General Internal Medicine in Denver, Colorado on 26 May 2013 and was named the Top Abstract presented in the category of Quality Improvement/Patient Safety.

Conflicts of Interest

The authors declare no conflicts of interest pertaining to this work.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Gina R. Kruse MD, MS, MPH.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kruse, G.R., Khan, S.M., Zaslavsky, A.M. et al. Overuse of Colonoscopy for Colorectal Cancer Screening and Surveillance. J GEN INTERN MED 30, 277–283 (2015).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: