Virtual colonoscopy:

A storm is brewing

David J. Vining, MD

A
storm is brewing around virtual
colonoscopy (VC) and whether
radiologists or gastroenterolo-
gists will ultimately control this technol-
ogy. Imagine the following: in the near
future, a patient who requires colorectal
cancer (CRC) screening walks into a
local gastroenterologist’s office, obtains a
VC examination, which is read by a nurse
practitioner, and, following consultation
with a gastroenterologist, undergoes
immediate optical colonoscopy (OC) for
evaluation of tiny polyps that either can-
not be found or turn out to be residual
feces. Meanwhile, a radiologist working
with this practice interprets the CT data
for extracolonic findings in exchange for survival rate for early stage I CRC is patient using a single-slice helical CT
a small percentage of the total profes- 93%, but when it metastasizes to distant scanner and nearly 8 hours to process the
sional fee. The patient’s insurance (ie, organs and becomes stage IV disease, data for a fly-through, but today multi-
Medicare) is billed for both the VC and the survival rate decreases to 8%.1 detector CT scanners acquire the data in
OC, which taxpayers ultimately pay. If Unfortunately, many adults over the age a few seconds, and processing occurs in
this sounds far-fetched, read on.... of 50 do not undergo screening, and, as a real time using inexpensive computers.
result, CRC is more often diagnosed in Despite the technological advances
Virtual colonoscopy development advanced stages.2 Virtual colonoscopy that have occurred during the past decade
Colorectal cancer is the second lead- offers the public a more appealing and (eg, CO2 insufflation, multidetector
ing cause of cancer death in the United less invasive alternative for screening. CT scanners, stool tagging, computer-
States, but it is also one of the most pre- I performed the first VC, also known assisted diagnosis), a strong lobbying
ventable when screening is used to as CT colonography (CTC), at the Wake effort on the part of gastroenterologists
detect and treat early disease. The 5-year Forest University Health Sciences Cen- has delayed the availability of VC in the
ter in 1993. It has taken nearly 15 years United States. Since Congress approved
Dr. Vining is a Professor of Diagnostic for VC to mature and gain acceptance by reimbursement for CRC screening in the
Radiology and the Medical Director of policymakers. The basic technique con- 1997 Balanced Budget Act, the number
the Image Processing and Visualization sists of: 1) bowel cleansing and stool of colonoscopies conducted annually in
Laboratory, University of Texas M.D. tagging, 2) gas insufflation of the colon, the United States has increased from
Anderson Cancer Center, Houston, TX.
3) CT scanning of the abdomen/pelvis, 4 million in 2000 to >14 million in 2002.3
Dr. Vining discloses that he has received and 4) 2- and 3-dimensional image
royalties from Wake Forest University
and Bracco, Inc., for virtual colonoscopy- analysis of the data to identify polyps Handwriting on the wall
related products. and masses (Figure 1). The first VC Clinical trials that compared VC with
examination took 60 seconds to scan a OC have shown a dramatic improvement

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VIRTUAL COLONOSCOPY

A B

FIGURE 1. (A) This CT image shows a 10-mm polyp (arrow) on a fold in the sigmoid colon. (B) This 3-dimensional volume-rendered image
shows the polyp (arrow) from a superior perspective.

in VC accuracy in the last few years, cul-
minating in 2 major trials that were
announced in September 2007. The
ACRIN National Colonography Trial
enrolled over 2500 patients at 15 sites,
and it reported that VC had a 90% sen-
sitivity for the detection of polyps
>10 mm.4 Within a week, Kim5 pub-
lished a study comparing VC screening
in 3120 patients with OC screening in
3163 patients. Remarkably, VC and OC
found an equivalent number of ad-
vanced adenomas in each group; more
surprisingly, a larger number of cancers
were found in the VC group.5 These
2 studies plus multiple prior published
trials from the United States and abroad
led the American Cancer Society, the
American College of Radiology (ACR),
and the United States Multi-Society
Task Force to incorporate VC in its
screening recommendations that were
published in March 2008.6
As VC has gained acceptance, gastro-
enterologists now realize that VC will
impact their practice. After years of
bashing VC as not being good enough
and requiring more clinical data, the
Future Trends Committee of the Amer-
ican Gastroenterological Association
(AGA) published a report in October
2006 stating that they see the handwrit-
ing on the wall.7 This Committee pro-
posed that gastroenterologists should
position themselves to play a role in
performing and interpreting VC, in-
cluding advocating for CPT codes in
the 91000 series that will allow gastro-
enterologists to be reimbursed for inter-
preting and providing VC services, as
well as developing specialized training
and training requirements for those
interested in performing VC interpreta-
tion. In an effort to make good on its
promise, the AGA published a set of
guidelines in 2007 listing the minimum
requirements that a gastroenterologist
must satisfy in order to become certi-
fied to read VC examinations.8
Battle lines are drawn
Currently the Centers for Medicare and
Medicaid Services (CMS) approve reim-
bursement for VC only when it follows
a failed “diagnostic” colonoscopy, not a
failed “screening” colonoscopy (Fig-
ure 2).9 Following the inclusion of VC
in the American Cancer Society’s screen-
ing guidelines, CMS launched a National
Coverage Analysis for Screening
Computed Tomography Colonography
for Colorectal Cancer (CAG-00396N)
in May 2008. This seeks to expand reim-
bursement for screening indications. The
final report of this analysis is due in Febru-
ary 2009.10 Expanded reimbursement
could have a huge impact on increasing
screening and reducing CRC deaths, but it
could also have substantial economic con-
sequences for CMS and taxpayers. A pub-
lic comment period held May–June 2008
drew responses from many individuals
and organizations, including the ACR and
the AGA. Of course, the ACR is in favor
of expanded reimbursement, but the AGA
stated that it would support VC only if
certain conditions were met,11 including:
1. Reporting of ALL polyps (which is
contradictory to the ACR Practice
Guideline for the Performance of CTC
in Adults that states reporting of polyps
<5 mm is not recommended because of
the low incidence of those lesions hav-
ing malignant potential)12;
2. Allowing patients in consultation
with their physician to determine whether
or not to remove those polyps; and
3. Enacting a coverage policy that
would encourage rapid follow-up proce-
dures (ie, colonoscopy) and that corre-
spondingly would not create a dis-
incentive for physicians (ie, gastroen-
terologists) who refer those procedures.

14 ■ APPLIED RADIOLOGY ©
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 VIRTUAL COLONOSCOPY

A B

FIGURE 2. (A) Virtual colonoscopy (VC) shows a diverticular stricture (right arrow) that prevented colonoscopy from successfully evaluating the
entire colon. However, VC was able to identify an ascending colon cancer (left arrow) that was the cause of the patientʼs occult gastrointestinal
bleeding. (B) A close-up of the ascending colon cancer from a superior view.

Reading between the lines, if such
conditions are approved by CMS, then
the gastroenterologists will have an
unrestrained ability to perform colon-
oscopy on any little lump or bump that
they might discover if they or their clin-
ical assistant should be allowed to read
VC exams. It is also the position of
many prominent gastroenterologists to
create a split-fee arrangement with radi-
ologists so that radiologists will be rele-
gated to reading only the extracolonic
portions of a CT scan for a small portion
of the professional fee, and, if radiolo-
gists refuse to participate, then they will
outsource radiology services, even to
foreign providers!13
Dispelling popular myths
Gastroenterologists frequently try to
discredit VC with the following myths:
1. Colonoscopy is the “gold stan-
dard.” There are no published studies to
validate this claim. In fact, studies com-
paring back-to-back colonoscopies on
the same patients have reported OC miss
rates of 22% for polyps, even in the
hands of expert endoscopists.14 Studies
such as Pickhardt’s15 landmark VC study
have shown VC to outperform OC.
Finally, the accuracy of screening
colonoscopy has been shown to be de-
pendent on how much time a gastro-
enterologist spends performing the
examination.16
2. If VC finds a polyp, then colon-
oscopy is needed for polyp removal, so
why not undergo colonoscopy in the first
place? The vast majority of polyps are
benign, hyperplastic polyps, and <5% of
the asymptomatic screening population
has a significant adenomatous polyp.5
Hence, if OC is the primary screening
method, then >95% of the asymptomatic
population would undergo OC unneces-
sarily with its inherent risks of bowel
perforation and anesthesia.
3. The radiation dose associated with
VC is prohibitive. Radiation dose is a
valid concern, but researchers are striving
to mitigate this risk by using low-dose
techniques, even as low as 10 mAs (com-
pared with a conventional CT scan that
might use a dose of 200 mAs).17 Hence,
the radiation risk from VC with low-dose
techniques can be on the order of 1 to
2 mSv, which is far below the range that
has been associated with potential cancer
and multidetector CT use.18 Alternatively,
VC can be performed using MRI, but the
availability of MRI scanners is a tempo-
rary hurdle, at least for today.
Actions to take
Radiologists are already overworked
due to the exponential increase in imag-
ing studies during the past decade, and
as a result, we have become complacent
about the ownership of new technolo-
gies. In the meantime, gastroenterolo-
gists are purchasing CT scanners and
attending training programs to get ready
for CMS approval of reimbursement for
VC screening.19 However, if radiolo-
gists act quickly and take certain steps
to position ourselves to maintain control
of VC, we will not risk losing this tech-
nology, as we have done with cardiac
imaging. Some initiatives include:
1. Taking a stronger, vocal interest in
VC. Radiologists are better trained to
read an entire CT examination, espe-
cially when disease crosses organ
boundaries to involve both the colon and
adjacent anatomy. We need to establish
ourselves as the imaging experts in order
to counter claims that endoscopists and
nurse practitioners are as good as radiol-
ogists in reading VC exams.20
2. Beginning a dialogue with com-
munity gastroenterologists and primary
care physicians. Radiology practices
need to be willing to provide same-
day, on-demand VC services for failed

November 2008 www.appliedradiology.com APPLIED RADIOLOGY ©

■ 15
VIRTUAL COLONOSCOPY

“diagnostic” colonoscopy examinations
in advance of the anticipated reimburse-
ment for screening VC.
3. Developing practice guidelines for
appropriately working-up extracolonic
findings. Perhaps offering immediate but
limited ultrasound evaluation to resolve
indeterminate liver and renal lesions will
help to mitigate the gastroenterologists’
cry that they should be the ones perform-
ing VC in their offices.
4. Providing consistent, high-quality
reports of VC findings that can be
rapidly delivered to the patient and
referring clinician. Utilization of the
CT Colonography Reporting and Data
System (C-RADS) and participation in
the ACR’s CTC Registry will help to
strengthen our position in the field.21,22
5. Challenging any proposals by
gastroenterologists to split the profes-
sional fee for reading colonic and extra-
colonic portions of a VC CT scan, in-
cluding legislative lobbying if neces-
sary. There are many problems with
fee-splitting arrangements, not the least
of which is malpractice liability—radi-
ologists will certainly be held liable
when gastroenterologists fail to make a
correct diagnosis if they should be
allowed to interpret only the intralumi-
nal portion of a VC scan.
All is not lost, at least not yet
Much of the rhetoric coming from the
gastroenterology community is coming
from a few but very vocal and rabid gas-
troenterologists. In fact, a survey of 2400
AGA members regarding their interest in
VC resulted in only 588 responses, of
which one third said that they would
want to perform VC, another third said
that they would not perform it but would
support their colleagues, and the final
third said that gastroenterologists should
not perform VC.23 In reality, radiologists
and gastroenterologists will need to work
together along with surgeons and oncol-
ogists to provide comprehensive CRC
screening and treatment services. If CRC
screening really takes off, then there will
not be enough gastroenterologists avail-
able in this country to perform the neces-
sary therapeutic colonoscopies that will
be generated. Although radiologists spe-
cializing in VC may eventually become
employees of large, multispecialty clin-
ics specializing in colorectal disease, it is
paramount that the role and expertise of
the radiologist be maintained.
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