Barriers, Challenges to Compliance with New Bowel Prep Guidance

Colorectal cancer is the second leading cause of cancer-related death in the United States, a stark reality that underscores the need for effective screening and prevention.

Each March, Colorectal Cancer Awareness Month serves as a reminder of the importance of early detection to reduce colorectal cancer’s significant impact. Colonoscopy remains the gold-standard screening tool, but its effectiveness relies heavily on adequate bowel preparation. Inadequate preparation can lead to missed lesions, prolonged procedures, and the need for repeat exams, diminishing its preventive power.

New guidance from the US Multi-Society Task Force on Colorectal Cancer (USMSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, provides clinical recommendations to address challenges related to bowel preparation for colonoscopy, focusing specifically on outpatients at low risk for inadequate bowel preparation.

In the fourth segment of this 6-part HCPLive RX Review, Brian Jacobson, MD, MPH, and Joseph Anderson, MD, discuss potential patient and provider challenges that may impact compliance with the guidance.

Anderson acknowledges that while the updated guidelines are more patient-centered, logistical challenges remain, including compliance with split-dose bowel preparation. For patients, he points out the practical burden of waking early or traveling long distances can lead to incomplete preparation. Specifically, Anderson notes that a patient with an afternoon procedure may find it feasible to finish the prep by 10 AM, but early morning appointments often require patients to wake up at inconvenient hours, sacrificing sleep.

Provider practices also contribute to the challenge of assessing and improving bowel preparation quality. Anderson says some endoscopists do not consistently report the quality of bowel preparation using standardized scales, and while Jacobson notes the USMSTF does not endorse a specific scale, the guidance encourages documentation of bowel cleanliness as adequate or inadequate to properly assess adequacy rates.

Despite these challenges, Jacobson highlights the patient-centered approach of the updated guidelines, which include more flexible dietary options and practical tools like sample diets to simplify patient education. However, he acknowledges that some clinicians may still favor more intensive, "kitchen sink" preparations for patients perceived to be at higher risk of poor bowel prep. The USMSTF addresses these situations by recommending more extended preparation regimens — including prolonged clear liquid diets, higher-volume preps, and adjunctive agents like bisacodyl — for patients with predictors of inadequate bowel preparation or a history of suboptimal prep.

Moderator: Brian Jacobson, MD, MPH, an associate professor of medicine at Harvard Medical School and director of program development for gastroenterology at Massachusetts General Hospital

Panelist: Joseph Anderson, MD, a professor of medicine at Geisel School of Medicine at Dartmouth and a gastroenterologist at White River Junction VAMC

Editors’ note: Jacobson has relevant disclosures with Curis and Guardant Health. Anderson has no relevant disclosures.

References

1. Jacobson BC, Anderson JC, Burke CA, et al. Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer. The American Journal of Gastroenterology. doi:10.14309/ajg.0000000000003287

2. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. doi:10.3322/caac.21763