Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer

Stress-Testing US Colorectal Cancer Screening Guidelines: Decennial Colonoscopy from Age 45 is Robust to Natural History Uncertainty and Colonoscopy Sensitivity Assumptions

PurposeThe 2023 American College of Physicians (ACP) guidelines for colorectal cancer (CRC) screening are at odds with the United States Preventive Task Force (USPSTF) guidelines, with the former recommending screening starting at age 50 y and the latter at age 45 y. This article "stress tests" CRC colonoscopy screening strategies to investigate their robustness to uncertainties stemming from the natural history of disease and sensitivity of colonoscopy.MethodsThis study uses the CRC-SPIN microsimulation model to project the life-years gained (LYG) under several colonoscopy CRC screening strategies. The model was extended to include birth cohort effects on adenoma risk. We estimated natural history parameters under 2 different assumptions about the youngest age of adenoma initiation. For each, we generated 500 parameter sets to reflect uncertainty in the natural history parameters. We simulated 26 colonoscopy screening strategies and examined 4 different colonoscopy sensitivity assumptions, encompassing the range of sensitivities consistent with prior tandem colonoscopy studies. Across this set of scenarios, we identify efficient screening strategies and report posterior credible intervals for benefits of screening (LYG), burden (number of colonoscopies), and incremental burden-effectiveness ratios.ResultsProjected absolute screening benefits varied widely based on assumptions, but strategies starting at age 45 y were consistently in the efficiency frontier. Strategies in which screening starts at age 50 y with 10-y intervals were never efficient, saving fewer life-years than starting screening at age 45 y and performing colonoscopies every 15 y while requiring more colonoscopies per person.ConclusionsDecennial colonoscopy screening initiation at age 45 y remained a robust recommendation. Colonoscopy screening with a 10-y interval starting at age 50 y did not result in an efficient use of colonoscopies in any of the scenarios evaluated.HighlightsColorectal cancer colonoscopy screening strategies initiated at age 45 y were projected to yield more life-years gained while requiring the least number of colonoscopies across different model assumptions about disease natural history and colonoscopy sensitivity.Colonoscopy screening starting at age 50 y with a 10-y interval consistently underperformed strategies that started at age 45 y.

Clinical management of patients with colorectal intramucosal carcinoma compared to high-grade dysplasia and T1 colorectal cancer

BACKGROUND AND AIMS

In the colorectum, intramucosal carcinoma (IMC), like high-grade dysplasia (HGD), should be resected endoscopically. We were interested to understand how real-world treatment of IMC cases compares to management of HGD and T1 colorectal cancer (CRC).

METHODS

A multicenter cohort study was conducted. Through pathology databases, all patients diagnosed between 2010 and 2019 with HGD, IMC, or T1 CRC polyps at 3 hospitals in a regional Canadian center were identified. The primary outcome was the proportion of surgical management of IMC compared to HGD after complete endoscopic resection. Secondary outcomes were the proportion of synchronous advanced neoplasia (SAN) and the adjusted hazard ratios (aHRs) for metachronous advanced neoplasia (MAN) in the 3 groups among patients eligible for follow-up.

RESULTS

We identified 753 patients with IMC or HGD on a first pathology diagnosis, including 601 after complete endoscopic resection. Patients with IMC were more likely to undergo surgery after complete endoscopic resection compared to patients with HGD (10.5% [6 of 57] vs 0% [0 of 544], P < .001). A total of 455 patients had follow-up endoscopy and pathology (mean age, 67.1 years; 42.2% female; median follow-up, 3.4 years): 269 with HGD, 60 with IMC, and 126 with T1 CRC. Proportions of SAN were 24.2%, 26.7%, and 25.4% (P = .908). Compared to HGD, patients with IMC and T1 CRC had similar MAN risks (aHR, 0.82 [95% CI, 0.43-1.59] and aHR, 1.16 [95% CI, 0.66-2.05], respectively). No lymph node findings were positive (0 of 363), and no metastasis occurred among patients with IMC.

CONCLUSIONS

Patients diagnosed with colorectal IMC were more likely to undergo surgery after complete endoscopic resection than when HGD was diagnosed, although they were not at increased risk of SAN or MAN in this study, and the known risk of nodal metastasis with colorectal IMC is small (0%-2%). Unless a patient diagnosed with IMC is particularly concerned with this small risk, complete endoscopic resection should be considered the definitive treatment for IMC and should not be followed by surgery.

Leaving colorectal polyps in situ with endocytoscopy assisted by computer-aided diagnosis: a cost-effectiveness study

BACKGROUND

 Computer-aided diagnosis (CADx) enables the distinction between neoplastic and non-neoplastic polyps during colonoscopy. We aimed to estimate the patient-level benefit and harm of CADx.

METHODS

 We conducted a comparative analysis on data from the EndoBRAIN international clinical trial, evaluating the effect of optical diagnosis during colonoscopy with and without CADx. Three hypothetical scenarios were compared: "endoscopist-alone" and "CADx-assisted" leave-in-situ strategies (leaving non-neoplastic rectosigmoid polyps ≤ 5 mm), and "total removal" (removing all detected polyps). Primary outcomes included patient-level colonoscopy-related cost and surveillance interval agreement (colorectal cancer risk category). Estimates were calculated based on national reimbursement rates and guidelines in four countries.

RESULTS

 We analyzed 1134 patients (59 % men, median age 67 years) with 1716 polyps. Compared with total removal, the endoscopist-alone and CADx-assisted leave-in-situ strategies reduced the removed polyps per patient from 1.51 (95 %CI 1.48-1.54) to 1.18 (95 %CI 1.16-1.20) and 1.12 (95 %CI 1.00-1.14), respectively; however, 0.023 (95 %CI 0.015-0.033) and 0.021 (95 %CI 0.014-0.031) neoplasms per patient were left in situ, respectively. The mean colonoscopy cost decreased by $44 (endoscopist alone) and $46 (CADx assistance) in the USA, $22 and $19 in the UK, $21 and $19 in Japan, and $32 and $30 in Norway, respectively. Surveillance interval agreement decreased to 99.2 % (endoscopist alone) and 99.0 % (CADx assistance) in the USA, 99.8 % and 99.8 % in the UK, 97.9 % and 97.1 % in Japan, and 99.9 % and 99.9 % in Norway, respectively.

CONCLUSIONS

 Both endoscopist-alone and CADx-assisted optical diagnosis reduce colonoscopy costs. The risk of missed adenomas and surveillance interval deviations appear marginal.

Polyp-Size: A Precise Endoscopic Dataset for AI-Driven Polyp Sizing

Colorectal cancer often arises from precancerous polyps, where accurate size assessment is vital for clinical decisions but challenged by subjective methods. While artificial intelligence (AI) has shown promise in improving the accuracy of polyp size estimation, its development depends on large, meticulously annotated datasets. We present Polyp-Size, a dataset of 42 high-resolution white-light colonoscopy videos with polyp sizes precisely measured post-resection using vernier calipers to submillimeter precision. Unlike existing datasets primarily focused on polyp detection or segmentation, Polyp-Size offers validated size annotations, diverse polyp features (Paris classification, anatomical location and histological type), and standardized video formats, enabling robust AI models for size estimation. By making this resource publicly available, we aim to foster research collaboration and innovation in automated polyp measurement to ultimately improve clinical practice.

Photodocumentation of Large Colorectal Polyps: An Audit of Image Quality

BACKGROUND

Numerous guidelines recommend photodocumentation (PD) of large colorectal polyps ≥10 mm (LP) preresection relative to an open snare or forceps, and suggests postresection PD of the clear resection base. However, no quality metrics have been proposed. We recently reported that preresection and postresection PD occurred in 82% and 52% of 1693 resected LPs, respectively; however, the quality of PD was not ascertained.

AIMS

To assess the quality of preresection and postresection PD of LPs based on consensus definitions.

METHODS

Images of LPs resected between 2016 and 2021 were reviewed by 3 gastroenterologists and 1 fellow for assessment of (1) high-quality preresection PD (enough polyp visualized to estimate size), (2) presence of a tool relative to the LP, (3) estimated polyp size, and (4) high-quality postresection PD (clean base without visible polyp tissue). Confidence levels in PD quality assessment and estimated size were provided. Agreement on size was assessed using free-marginal kappa.

RESULTS

One hundred ninety-nine LPs with both preresection and postresection images were included. Reviewers' assessment of high-quality preresection PD ranged from 49% to 82% and 51% to 70% for high-quality postresection PD. One percent of preresection images demonstrated an open snare or forceps relative to the LP. Only 74% to 89% of polyps were estimated by reviewers to be ≥10 mm [Kappa=0.66 (95% CI: 0.48-0.64)]. High-level confidence in PD quality and size assessment was lowest in the fellow compared with established gastroenterologists.

CONCLUSIONS

Although guidelines recommend PD of LPs preresection and postresection, the quality of PD appears suboptimal. Quality standards in LP PD should be considered and the impact of high-quality PD on patient outcomes should be studied.

Machine learning in colorectal polyp surveillance: A paradigm shift in post-endoscopic mucosal resection follow-up

Colorectal cancer remains a major health concern, with colorectal polyps as key precursors. Endoscopic mucosal resection (EMR) is a common treatment, but recurrence rates remain high. Traditional surveillance strategies rely on polyp characteristics and completeness of the resection potentially missing key risk factors. Machine learning (ML) offers a transformative approach by integrating patient-specific data to refine risk stratification. Recent studies highlight ML models, such as Extreme Gradient Boosting, which outperform conventional methods in predicting polyp recurrence within one-year post-EMR. These models incorporate factors like age, smoking status, family history, and pathology, optimizing follow-up recommendations and minimizing unnecessary procedures. Artificial intelligence (AI)-driven tools and web-based calculators enhance clinical workflow by providing real-time, personalized risk assessments. However, challenges remain in external validation, model interpretability, and clinical integration. Future surveillance strategies should combine expert judgment with AI insights to optimize patient outcomes. As gastroenterology embraces AI, ML-driven surveillance represents a paradigm shift, advancing precision medicine in colorectal polyp management. This editorial explores AI’s role in transforming post-EMR follow-up, addressing benefits, limitations, and future directions.

Artificial intelligence system improves the quality of digestive endoscopy: A prospective pretest and post-test single-center clinical trial

BACKGROUND

With the assistance of ENDOANGEL, a study was conducted at Hainan General Hospital to evaluate the effect of artificial intelligence (AI) system on the detection of gastrointestinal precancerous lesions.

METHODS

The prospective, randomized, pretest and post-test, single-center clinical trial compared the detection rates of gastric precancerous lesions and intestinal adenomas between baseline and post-intervention phase among traditional digestive endoscopy (control groups i and ii, and experimental group i) and AI-assisted endoscopy (experimental group ii). Additionally, the effect of AI on the detection rate of different seniority physicians was analyzed.

RESULTS

AI assistance significantly increased the detection rates of intestinal metaplasia (experimental group ii vs control group ii: 14.23 % vs 9.15 %, P = 0.013), atrophy (experimental group ii vs control group ii: 22.76 % vs 17.28 %, P = 0.031) and intestinal adenomas (experimental group ii vs control group ii: 48.52 % vs 24.58 %, P < 0.001). The improvement was particularly notable among junior doctors, with significant enhancements in the detection rates of intestinal metaplasia (experimental group ii vs control group ii: 14.39 % vs 9.09 %, P = 0.008), atrophy (experimental group ii vs control group ii: 22.04 % vs 15.31 %, P = 0.004), and intestinal adenomas (experimental group ii vs control group ii: 45.18 % vs 29.27 %, P = 0.002).

CONCLUSIONS

AI systems have the potential to significantly improve the detection rates of precancerous conditions, particularly among less experienced endoscopists. This advancement can lead to more accurate and appropriate follow-up and review strategies for patients, ultimately reducing the risk of missed early cancer diagnoses.

Demographic and Clinicopathologic Risk Factors for Colorectal Adenoma Recurrence: A Large-Scale Surveillance Cohort Study of 59,667 Adults

Background

Current colorectal surveillance guidelines emphasize adenoma characteristics but overlook temporal, racial, and sex-based heterogeneity in recurrence risk- an gap that limits equitable and personalized care. To evaluate the associations of demographic factors, obesity, and adenoma features with recurrence risk over time in a large longitudinal surveillance cohort.

Methods

This retrospective cohort study included 59,667 adults who underwent their first colonoscopic polypectomy between January 1990 and July 2024 at a tertiary medical center. Median follow-up was 4 years. Demographic variables included race and ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic, Asian or Pacific Islander [API]), sex, obesity (BMI >30), family history of colorectal cancer (CRC) or polyps, and age at adenoma onset (<50 vs ≥50 years). Adenoma features included histology, size, number, and dysplasia. The primary outcome was recurrence-free survival, defined as time from initial polypectomy to histologically confirmed recurrence. Cox proportional hazards models estimated associations adjusted for confounders, with stratified analyses over 5-, 10-, and >10-year follow-up intervals.

Findings

Among 59,667 patients, 17,596 (29.5%) experienced recurrence within 5 years, revealing substantial temporal heterogeneity. Early recurrence was associated with male sex (adjusted hazard ratio [aHR], 1.10; 95% CI, 1.06-1.14), obesity (aHR, 1.18; 95% CI, 1.13-1.23), early-onset adenomas (aHR, 1.17; 95% CI, 1.11-1.23), and family history of CRC (aHR, 1.24; 95% CI, 1.18-1.31). Compared with NHW patients, NHB individuals had lower early recurrence risk (aHR, 0.89; 95% CI, 0.83-0.96) but higher late recurrence (>10 years; aHR, 1.26; 95% CI, 1.06-1.50). API patients had a similar shift, with lower early risk (aHR, 0.80; 95% CI, 0.67- 0.96) and elevated mid-term risk (5-10 years; aHR, 1.40; 95% CI, 1.08-1.81). High-grade dysplasia (aHR 2.86; 95% CI, 2.54-3.22) and villous histology (aHR 2.55; 95% CI, 2.31-2.81showed the largest effect sizes for early recurrence. Females had stronger associations with tubulovillous histology, mixed adenomas, and large lesions.

Interpretation

Temporal, demographic, and histologic differences in adenoma recurrence highlight the need for surveillance strategies that incorporate population- and time-specific risk profiles to enhance colorectal cancer prevention.

Funding

This work was supported by the National Cancer Institute (Grant No. R37CA227130 to Xingyi Guo).

Research in context

Evidence before this study: We conducted a PubMed search for publications dated before June 2024 using combinations of keywords such as "colonoscopic polypectomy," "Demographic and Clinicopathologic Risk Factors," "Vannderbilt," and "electronic health records." We found no studies that comprehensively evaluated the associations of demographic characteristics, obesity, and adenoma features with recurrence risk over time in a large, longitudinal surveillance cohort.Added Value of This Study: Using a longitudinal cohort of 59,667 patients, our study reveals substantial temporal heterogeneity in adenoma recurrence. Non-Hispanic Black and Asian or Pacific Islander individuals exhibited a lower risk of recurrence within the first 5 years but experienced increased risk at 5-10 and >10 years post-polypectomy. Females showed heightened early recurrence risk, particularly when initial adenomas were tubulovillous, mixed-type, or large. Early recurrence was predominantly driven by high-grade dysplasia, high-risk adenomas, villous or tubulovillous histology, and multiplicity.Implications of All the Available Evidence: These findings highlight the critical need to recognize and address temporal, racial, and sex-specific heterogeneity in adenoma recurrence risk. The observed variability in histopathologic and demographic factors over time underscores the importance of personalized, adaptive surveillance strategies to reduce adenoma recurrence and enhance colorectal cancer prevention.

How Good Is Good Enough? What Should Be the Target for CRC Screening?

Colorectal Cancer (CRC) screening of average-risk individuals has been shown to reduce CRC mortality and incidence. Incidence is reduced by detection and removal of cancer precursor lesions (CPLs), resulting in cancer prevention. Mortality reduction is achieved with detection of curable CRC, as well as prevention by removing CPLs before cancer develops. Targets of screening include both curable CRC and CPLs. Non-invasive stool tests are a multi-step screening program which can detect curable cancers and less likely to detect CPLs than invasive screening. The non-invasive programs depend on completion of colonoscopy if the test is positive. Invasive screening with colonoscopy is a one-step test program, with excellent detection of both curable CRCs and CPLs, if performed with high-quality. Current evidence suggests that either program could be effective, despite different targets. Patient adherence and program quality are perhaps the important determinants of program effectiveness.

Endoscopic size measurement of colorectal polyps: a systematic review of techniques

Accurate size measurement of colorectal polyps is critical for clinical decision making and patient management. This systematic review aimed to evaluate the current techniques used for colonic polyp measurement to improve the reliability of size estimations in routine practice.A comprehensive literature search was conducted across PubMed, EMBASE, and MEDLINE to identify studies relevant to size measurement techniques published between 1980 and March 2024. The primary outcome was the accuracy of polyp sizing techniques used during colonoscopy.61 studies were included with 34 focusing on unassisted and assisted endoscopic visual estimation and 27 on computer-based tools. There was significant variability in visual size estimation among endoscopists. The most accurate techniques identified were computer-based systems, such as virtual scale endoscopes (VSE) and artificial intelligence (AI)-based systems. The least accurate techniques were visual or snare-based polyp size estimation. VSE assists endoscopists by providing an adaptive scale for real-time, direct, in vivo polyp measurements, while AI systems offer size measurements independent of the endoscopist's subjective judgment.This review highlights the need for standardized, accurate, and accessible techniques to optimize sizing accuracy during endoscopic procedures. There is no consensus on a gold standard for measuring polyps during colonoscopy. While biopsy forceps, snare, and graduated devices can improve the accuracy of visual size estimation, their clinical implementation is limited by practical, time, and cost challenges. Computer-based techniques will likely offer improved accuracy of polyp sizing in the near future.

Virtual scale endoscope versus snares for accuracy of size measurement of smaller colorectal polyps: a randomized controlled trial

Accurate measurement of polyp size during colonoscopy is crucial for informing clinical decisions such as resection technique and surveillance scheduling. This study aimed to compare the accuracy of polyp size measurement when using a virtual scale endoscope (VSE) or snare-based polyp size measurement.This randomized controlled trial enrolled 221 patients undergoing screening, surveillance, or diagnostic outpatient colonoscopies. Study subjects were randomized to have polyps detected during the colonoscopy measured for size either using the VSE or a snare of known size to estimate the size of each polyp. All polyps were measured for reference size directly after their removal from the colon using a digital caliper and before formalin fixation.93 polyps were included in the VSE group and 102 in the snare group. The VSE demonstrated significantly higher relative accuracy (80.0% [95%CI 77.0%-82.9%]) compared with snare-based size estimation (66.4% [95%CI 62.4%-70.5%]; P < 0.001). Misclassification rates were lower with the VSE for polyps >2 mm (13.1% vs. 39.3%) and >3 mm (22.6% vs. 55.4%). For diminutive polyps, the VSE better prevented misclassification of >5 mm polyps as 1-5 mm (21.4% vs. 73.0%). The VSE also outperformed snare-based estimation in measuring within 10% of the reference standard size (30.1% vs. 18.6%) and had lower rates of size underestimation (36.5% vs. 65.7%).Using the VSE improves the accuracy of polyp size measurement during colonoscopy in comparison with snare-based size estimation. In clinical scenarios, the VSE reduced misclassifications at clinically relevant size thresholds 2, 3, and 5 mm, which is relevant for the correct choice of polypectomy technique or when implementing resect-and-discard strategies.

CHOICE: A Comprehensive and Coordinated Colorectal Cancer Screening Program in a Large Urban Health System

OBJECTIVE

To develop a coordinated colorectal cancer (CRC) screening program within a large urban health system, with the ultimate goal of increasing system-wide screening rates of eligible patients and reducing no-show rates while increasing colonoscopy completion rates.

STUDY SETTING

A large urban academic health system comprising 8 hospitals and over 400 ambulatory practices.

STUDY DESIGN

The CHOICE Program combined patient navigation, electronic medical record (EMR) optimization, and system-wide practice changes to improve CRC screening completion by colonoscopy. The program incorporates provider and patient education, standardization of documentation and protocols, increased outreach by navigators, and streamlining of patient scheduling. The primary outcome is colonoscopy completion.

DATA COLLECTION

All health system patients between the ages of 45 and 75 and at average risk of CRC are the target population for the intervention. A review of screen-eligible patients' completion of colonoscopy was performed to assess program success.

PRINCIPAL FINDINGS

During a 2-year period (March 2022 to February 2024), 18,119 people were referred into the program, and 79% of scheduled patients completed the colonoscopy. The CHOICE program operationalized and standardized the CRC screening efforts of a large health system and offers a template that can be implemented or adapted by other hospital systems and provider networks.

Large language models for extracting histopathologic diagnoses of colorectal cancer and dysplasia from electronic health records

Background

Accurate data resources are essential for impactful medical research, but available structured datasets are often incomplete or inaccurate. Recent advances in open-weight large language models (LLMs) enable more accurate data extraction from unstructured text in electronic health records (EHRs) but have not yet been thoroughly validated for challenging diagnoses such as inflammatory bowel disease (IBD)-related neoplasia.

Objective

Create a validated approach using LLMs for identifying histopathologic diagnoses in pathology reports from the nationwide Veterans Health Administration database, including patients with genotype data within the Million Veteran Program (MVP) biobank.

Design

Our approach utilizes simple 'yes/no' question prompts for following phenotypes of interest: any colorectal dysplasia, high-grade dysplasia and/or colorectal adenocarcinoma (HGD/CRC), and invasive CRC. We validated the method on diagnostic tasks by applying prompts to reports from patients with IBD (and validated separately in non-IBD) and calculated F-1 scores as a balanced accuracy measure.

Results

In patients with IBD in MVP, we achieved F1-scores of 96.1% (95% CI 92.5-99.4%) for identifying dysplasia, 93.7% (88.2-98.4%) for identifying HGD/CRC, and 98% (96.3-99.4%) for identifying CRC. In patients without IBD in MVP, we achieved F1-scores of 99.2% (98.2-100%) for identifying any colorectal dysplasia, 96.5% (93.0-99.2%) for identifying HGD/CRC, and 95% (92.8-97.2%) for identifying CRC using LLM Gemma-2.

Conclusion

LLMs provided excellent accuracy in extracting the diagnoses of interest from EHRs. Our validated methods generalized to unstructured pathology notes, even withstanding challenges of resource-limited computing environments. This may therefore be a promising approach for other clinical phenotypes given the minimal human-led development required.

Artificial Intelligence in Endoscopy Quality Measures

Quality of gastrointestinal endoscopy is a major determinant of its effectiveness. Artificial intelligence (AI) has the potential to enhance quality monitoring and improve endoscopy outcomes. This article reviews the current literature on AI algorithms that have been developed for endoscopy quality assessment.

Effects of Chinese herbal medicine on colorectal adenoma recurrence following polypectomy: a systematic review and meta-analysis

Objective

Preventing colorectal adenoma (CRA) recurrence after polypectomy is essential. However, the current evidence of Chinese herbal medicine (CHM) for CRA recurrence is still limited. This study aims to synthesize the effects of CHM as a prevention method for CRA recurrence.

Methods

Nine databases were searched up to May 2024. Randomised controlled trials identifying the preventive effects of CHM among people with CRA post-polypectomy were included. spreadsheets were used to collect and extract data. RevMan and STATA were used for data analysis. We performed subgroup and sensitivity analyses to explore potentially influencing variables.

Results

Twenty trials (2,325 participants) were included. The commonly used botanical drugs belonged to the categories of strengthening the spleen and anti-tumour metabolites. Compared to routine care (RC) alone, oral CHM plus RC significantly reduced the CRA recurrence rate at 12 months (RR 0.51, 95% CI [0.39, 0.67], I2 = 42%), 6 months (RR 0.44, 95% CI [0.36, 0.55], I2 = 0%), and 3 months (RR 0.46, 95% CI [0.22, 0.96], I2 = 0%) post-polypectomy. Compared to CHM placebo plus RC, San zi granule combined with RC significantly reduced CRA recurrence at 12 months post-polypectomy (RR 0.39, 95% CI [0.16, 0.93], I2 = 0%) and during the 2-year follow-up (RR 0.73, 95% CI [0.58, 0.90]). There were no significant differences between groups for treatment duration and syndromes. Additional analysis showed that oral CHM containing the botanical drugs of Si jun zi decoction plus RC reduced CRA recurrence at 12 months post-polypectomy with a low heterogeneity, compared to RC alone (RR 0.26, 95% CI [0.13, 0.54], I2 = 0%). Adverse events were similar in the above two comparisons.

Conclusion

Oral CHM combined with RC may reduce CRA recurrence and be well-tolerated. San zi granule and Si jun zi decoction may be representative prescriptions Experimental studies of the frequent botanical drugs have found anti-cancer effects that may account for the clinical findings. Future rigorous clinical trials are needed due to low-to-moderate certainty of evidence.

Systematic Review Registration

PROSPERO (CRD42023324197), https://www.crd.york.ac.uk/PROSPERO/view/CRD42023324197.

Acetic Acid-Indigo Carmine Chromocolonoscopy for Proximal Serrated Lesions: A Randomized, 3-Arm Colonoscopy Study

INTRODUCTION

Aggressive colorectal cancer (CRC) frequently originates from serrated lesions (SLs), particularly in the proximal colon, which are challenging to detect using standard screening colonoscopy. Although duplicate examinations or chromocolonoscopies are recommended for detecting proximal SLs, evidence from randomized trials is limited. We evaluated the effectiveness of tandem colonoscopy with an acetic acid-indigo carmine mixture (AIM) for detecting SLs in the proximal colon compared with white-light imaging (WLI) and indigo carmine (IC).

METHODS

This 3-arm, multicenter, randomized controlled trial involving 9 institutions enrolled patients undergoing colonoscopy and assigned them randomly to the WLI, IC, or AIM group. The primary outcomes were the SL-detection rate (SDR) of proximal lesions during the second examination (SDR 2nd ) and SL additional rate (SAR). Secondary outcomes included the detection and additional rates of other polyps, factors contributing to SAR, and complications.

RESULTS

Between 2021 and 2024, 1,319 participants with 1,267 polyps were included in the analysis. With AIM, the SDR 2nd and SAR were significantly higher compared with WLI or IC (WLI vs AIM: 2.7% vs 14.0%, P < 0.001; IC vs AIM: 7.9% vs 14.0%, P = 0.002, and WLI vs AIM: 22.4% vs 69.3%, P < 0.001; IC vs AIM: 45.8% vs 69.3%, P = 0.001). AIM conferred a higher adenoma detection rate 2nd than with WLI (10.5% vs 24.7%; P < 0.001) and was an independent factor for SAR (odds ratio [95% confidence interval]: 7.79 [3.76-17.08]). No major adverse events were observed.

DISCUSSION

AIM significantly improved proximal colon SDRs and outperformed WLI and IC. The relationship between SDR and CRC incidence warrants further investigation.

One in three adenomas could be missed by white-light colonoscopy - findings from a systematic review and meta-analysis

BACKGROUND

White light (conventional) colonoscopy (WLC) is widely used for colorectal cancer screening, diagnosis and surveillance but endoscopists may fail to detect adenomas. Our goal was to assess and synthesize overall and subgroup-specific adenoma miss rates (AMR) of WLC in daily practice.

METHODS

We conducted a systematic review in MEDLINE, EMBASE, Cochrane Library, and grey literature on studies evaluating diagnostic WLC accuracy in tandem studies with novel-colonoscopic technologies (NCT) in subjects undergoing screening, diagnostic or surveillance colonoscopy. Information on study design, AMR overall and specific for adenoma size, histology, location, morphology and further outcomes were extracted and reported in standardized evidence tables. Study quality was assessed using the QUADAS-2 tool. Random-effects meta-analyses and meta-regression were performed to estimate pooled estimates for AMR with 95% confidence intervals (95% CI) and to explain heterogeneity.

RESULTS

Out of 5,963 identified studies, we included sixteen studies with 4,101 individuals in our meta-analysis. One in three adenomas (34%; 95% CI: 30-38%) was missed by WLC in daily practice individuals. Subgroup analyses showed significant AMR differences by size (36%, adenomas 1-5 mm; 27%, adenomas 6-9 mm; 12%, adenomas ≥ 10 mm), histology (non-advanced: 42%, advanced: 21%), morphology (flat: 50%, polypoid: 27%), but not by location (distal: 36%, proximal: 36%).

CONCLUSIONS

Based on our meta-analysis, one in three adenomas could be missed by WLC. This may significantly contribute to interval cancers. Our results should be considered in health technology assessment when interpreting sensitivity of fecal occult blood or other screening tests derived from studies using WLC as "gold standard".

The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of colorectal cancer, 2024 update

The 2024 updates of the Chinese Society of Clinical Oncology (CSCO) Clinical Guidelines for the diagnosis and treatment of colorectal cancer emphasize standardizing cancer treatment in China, highlighting the latest advancements in evidence-based medicine, healthcare resource access, and precision medicine in oncology. These updates address disparities in epidemiological trends, clinicopathological characteristics, tumor biology, treatment approaches, and drug selection for colorectal cancer patients across diverse regions and backgrounds. Key revisions include adjustments to evidence levels for intensive treatment strategies, updates to regimens for deficient mismatch repair (dMMR)/ microsatellite instability-high (MSI-H) patients, proficient mismatch repair (pMMR)/ microsatellite stability (MSS) patients who have failed standard therapies, and rectal cancer patients with low recurrence risk. Additionally, recommendations for digital rectal examination and DNA polymerase epsilon (POLE)/ DNA polymerase delta 1 (POLD1) gene mutation testing have been strengthened. The 2024 CSCO Guidelines are based on both Chinese and international clinical research, as well as expert consensus, ensuring their relevance and applicability in clinical practice, while maintaining a commitment to scientific rigor, impartiality, and timely updates.

The Long-Term Risk of Metachronous Advanced Adenoma Recurrence After Endoscopic Submucosal Dissection for Colorectal Neoplasia: A Propensity-Score Matched Longitudinal Cohort With 5-Year Follow-Up

INTRODUCTION

Long-term data on metachronous advanced adenoma (AA) recurrence after endoscopic submucosal dissection (ESD) remain scarce, leading to a lack of a standardized surveillance strategy. This study aims to evaluate the long-term risk of recurrent AA after ESD.

MATERIALS AND METHODS

A longitudinal retrospective cohort study with propensity-score matching was conducted in a tertiary hospital in Hong Kong. Subjects who underwent colorectal ESD between 2011 and 2017 were enrolled and defined as the post-ESD group. Selected subjects who underwent polypectomy in their index colonoscopy between 2011 and 2017 were enrolled and stratified into the low- intermediate- and the high-risk groups according to the US Multi-Society Task Force (USMSTF) guideline. The risks of recurrent AA were assessed by Cox proportional hazards regression in the matched cohorts.

RESULTS

A total of 1745 subjects were included, with 203 post-ESD subjects fully matched with 729 high-risk and 813 low-intermediate-risk subjects, respectively. The 5-year cumulative incidence of recurrent AA in the post-ESD group was 7.8%. After 5 years, the post-ESD group was not associated with a higher rate of recurrent AA to the low-intermediate-risk group (7.8% vs. 5.5%; adjusted HR [aHR] 1.64, 95% CI 0.77-3.48, p = 0.197) but a lower rate of recurrent AA (7.8% vs. 11.8%; aHR 0.40, 95% CI 0.19-0.85, p = 0.017) than the high-risk group.

CONCLUSION

Subjects who underwent ESD were not associated with an increased 5-year risk of metachronous AA recurrence than low-intermediate or high-risk groups in USMSTF. The findings will inform future guidelines on post-ESD surveillance colonoscopy strategies.

Fecal Immunochemical Test to Detect Colorectal Neoplasia in Lynch Syndrome: A Prospective Multicenter Study

INTRODUCTION

Colonoscopy surveillance for Lynch syndrome is burdensome and postcolonoscopy colorectal cancers (CRCs) still occur. The noninvasive fecal immunochemical test (FIT) might guide optimal colonoscopy intervals.

METHODS

Prospective, multicenter observational study in which individuals with Lynch syndrome performed a quantitative FIT before high-quality surveillance colonoscopy. Diagnostic performance of FIT at various thresholds ≤20 μg Hb/g feces was assessed for relevant neoplasia, including advanced neoplasia (CRC, advanced adenomas [AAs] and advanced serrated lesions [ASLs]) and non-advanced adenomas (NAAs).

RESULTS

Of the 217 included individuals (59% female, median age 51 years), 4 had CRC, 5 AA, 4 ASL, and 57 NAA as most relevant neoplasia. The lowest FIT positivity threshold (2.5 μg Hb/g feces, 14% positivity rate) maximized detection: 4/4 CRCs, 4/5 AA, 1/4 ASL, and 9/57 NAA were detected, resulting in a sensitivity and negative predictive value of, respectively, 89% and 99% for CRC plus AA, 69% and 97% for advanced neoplasia, and 26% and 72% for all relevant neoplasia (91% specificity for all groups). At equal sensitivity and negative predictive value, specificity for advanced neoplasia optimized to 94% at threshold 4.1 μg/g. Per 100 FITs at threshold 4.1 μg/g, 11 individuals would test positive and thus proceed to colonoscopy, 2 individuals with advanced neoplasia would be missed and 3 individuals would need colonoscopy to detect 1 advanced neoplasia.

DISCUSSION

FIT at thresholds ≤4.1 μg Hb/g feces may be a promising strategy to postpone colonoscopy in approximately 9 of 10 individuals with Lynch syndrome. Large validation studies that also provide gene variant-specific outcomes should be prioritized.

Cold Snare Resection in the Colorectum: When to Choose it, When to Avoid it, and How to Do it

Cold snaring is now the preferred resection method for the majority of colorectal polyps encountered during colonoscopy. A key advantage of cold resection over resection utilizing electrocautery is a substantially lower risk of delayed hemorrhage. Cold snare resection is preferred for all lesions ≤10 mm and for nondysplastic sessile serrated lesions of any size but should be avoided when lesions have a significant risk of submucosal invasion or fibrosis. Cold snare resection can be considered for certain lesions 11-19 mm in size and some lateral spreading lesions ≥20 mm. This review discusses tips and techniques to optimize cold snare resection.

"Artificial histology" in colonic Neoplasia: A critical approach

BACKGROUND

The histological assessment of colorectal precancer and cancer lesions is challenging and primarily impacts the clinical strategies of secondary colon cancer prevention. Artificial intelligence (AI) models may potentially assist in the histological diagnosis of this spectrum of phenotypical changes.

OBJECTIVES

To provide a current overview of the evidence on AI-based methods for histologically assessing colonic precancer and cancer lesions.

METHODS

Based on the available studies, this review focuses on the reliability of AI-driven models in ranking the histological phenotypes included in colonic oncogenesis.

RESULTS

This review acknowledges the efforts to shift from subjective pathologists-based to more objective AI-based histological phenotyping. However, it also points out significant limitations and areas that require improvement.

CONCLUSIONS

Current AI-driven methods have not yet achieved the expected level of clinical effectiveness, and there are still significant ethical concerns that need careful consideration. The integration of "artificial histology" into diagnostic practice requires further efforts to combine advancements in engineering techniques with the expertise of pathologists.

Taking the Guess Work Out of Endoscopic Polyp Measurement: From Traditional Methods to AI

Colonoscopy is a crucial tool for evaluating lower gastrointestinal disease, monitoring high-risk patients for colorectal neoplasia, and screening for colorectal cancer. In the United States, over 14 million colonoscopies are performed annually, with a significant portion dedicated to post-polypectomy follow-up. Accurate measurement of colorectal polyp size during colonoscopy is essential, as it influences patient management, including the determination of surveillance intervals, resection strategies, and the assessment of malignancy risk. Despite its importance, many endoscopists typically rely on visual estimation alone, which is often imprecise due to technological and human biases, frequently leading to overestimations of polyp size and unnecessarily shortened surveillance intervals. To address these challenges, multiple tools and technologies have been developed to enhance the accuracy of polyp size estimation. The review examines the evolution of polyp measurement techniques, ranging from through-the-scope tools to computer-based and artificial intelligence-assisted technologies.

ARE QUALITY INDICATORS IMPORTANT IN COLONOSCOPIES? ANALYSIS OF 3,076 EXAMS IN A PRIVATE TERTIARY SERVICE IN SOUTHEASTERN BRAZIL

BACKGROUND

The carcinogenesis of colorectal cancer is well understood. Adenomas are the precursor lesions in about 70% of cases, highlighting the importance of screening programs.

AIMS

The aim of this study was to analyze the effectiveness of colonoscopy examinations performed in a private tertiary service by calculating the polyp detection rate (PDR) and adenoma detection rate (ADR) and comparing these rates with literature data.

METHODS

This retrospective observational study evaluated colonoscopies performed at Hospital Centro Médico de Campinas between 2018 and 2020. It assessed the indications and complications of colonoscopy, sex, age group, bowel preparation, cecal intubation rate, ADR, PDR, and advanced adenoma detection rate (AADR).

RESULTS

During the period, 3,686 colonoscopies were performed, and 3,076 were included in the analysis. The mean patient age was 57.2 years, and most patients were female (53.5%). Complications occurred in 39 colonoscopies (1.3%), with bleeding in six cases and perforation in one case. Tubular adenoma was the most prevalent histological subtype found in 20% of tests and in 62.7% of those with positive findings. The PDR was 23% and significantly increased with advancing age (p<0.01). The ADR was 20% and also significantly increased with age (p<0.001). This rate was higher in men (27%). The AADR was 4%.

CONCLUSIONS

Colonoscopy is an effective polyp detection method, and the PDR was higher in men and significantly increased with age. The ADR and AADR were comparable to the literature data.

Risk factors, prevention and screening of colorectal cancer: A rising problem

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer death worldwide. The leading risk factors for CRC include male gender, age over 50, family history, obesity, tobacco smoking, alcohol consumption, and unhealthy diet. CRC screening methods vary considerably between countries and depend on incidence, economic resources and healthcare structure. Important aspects of screening include adherence, which can vary significantly across ethnic and socioeconomic groups. Basic concepts of CRC screening include pre-stratification of patients by identifying risk factors and then using fecal immunochemical test or guaiac-based fecal occult blood test and/or colonoscopy or radiologic imaging techniques. Technological capabilities for CRC screening are rapidly evolving and include stool DNA test, liquid biopsy, virtual colonography, and the use of artificial intelligence. A CRC prevention strategy should be comprehensive and include active patient education along with targeted implementation of screening.

Yes-associated protein plays oncogenic roles in human sporadic colorectal adenomas

The role of Hippo-Yes-associated protein (YAP) in human colorectal cancer (CRC) presents contradictory results. We examined the function of YAP in the early stages of CRC by quantitatively measuring the expression of phospho-YAPS127 (p-YAP) and five APC-related proteins in 145 sporadic adenomas from the Tennessee Colorectal Polyp Study, conducting APC sequencing for 114 adenomas, and analyzing YAP-correlated cancer pathways using gene expression data from 326 adenomas obtained from Gene Expression Omnibus. The p-YAP expression was significantly correlated with YAP expression (r = 0.53, P < .0001) and nuclear β-catenin (r = 0.26, P = .0018) in adenoma tissues. Both p-YAP and nuclear β-catenin were associated with APC mutations (P = .05). A strong association was observed between p-YAP overexpression and advanced adenoma odds (OR = 12.62, 95% CI = 4.57-34.86, P trend < .001), which persisted after adjusting for covariates and biomarkers (OR = 12.31, 95% CI = 3.78-40.10, P trend < .0001). P-YAP exhibited a sensitivity of 77.4% and specificity of 78.2% in defining advanced versus nonadvanced adenomas. Additionally, synergistic interaction was noted between p-YAP positivity and nuclear β-catenin on advanced adenomas (OR = 16.82, 95% CI = 4.41-64.08, P < .0001). YAP-correlated genes were significantly enriched in autophagy, unfolded protein response, and sirtuin pathways showing predominantly pro-tumorigenic alterations. Collectively, YAP plays an oncogenic role in interacting with Wnt as well as other cancer pathways within human sporadic adenomas. P-YAP could be a potential biomarker for human high-risk sporadic adenomas.

LGR5 as a diagnostic marker for dysplasia in serrated polyps

AIMS

WNT signalling pathway dysregulation is often a critical early component in colorectal neoplasia, particularly the chromosomal instability pathway. Using two WNT reporters, LGR5 and AXIN2, we sought to assess whether these polyps demonstrate predictable expression patterns and if these patterns show diagnostic value.

METHODS

We evaluated 23 adenomas (TA), 23 sessile serrated lesions (SSLs), 14 SSL with dysplasia and 38 traditional serrated adenomas (TSA). Chromogenic in situ hybridisation stains (ISH) for LGR5 and AXIN2 were performed. Reactivity was defined as strong, intermediate or weak. Upper third crypt reactivity was defined as full-thickness staining. Accentuation within ectopic crypts (ECF) was recorded.

RESULTS

TAs (91%) showed strong reactivity and full-thickness staining with LGR5. TSAs showed full-thickness and weak to intermediate LGR5 reactivity (79%) and ECF with LGR5 accentuation was exclusively seen in TSA. SSL showed weak LGR5 reactivity confined to the basal crypt region (100%). SSL with dysplasia also showed weak or intermediate (100%) LGR5 reactivity, but the reactivity pattern was full thickness (88%). AXIN2 expression parallels LGR5 expression (Pearson coefficient=0.63) regarding signal intensity for the examined polyp groups.

CONCLUSIONS

Qualitative and quantitative differences in AXIN2 and LGR5 expression assist in the diagnosis of SSL with dysplasia.

Cost-Effectiveness of Noninvasive Colorectal Cancer Screening in Community Clinics

Importance

Several noninvasive tests for colorectal cancer screening are available, but their effectiveness in settings with low adherence to screening and follow-up colonoscopy is not well documented.

Objective

To assess the cost-effectiveness of and outcomes associated with noninvasive colorectal cancer screening strategies, including new blood-based tests, in a population with low adherence to screening and ongoing surveillance colonoscopy.

Design, Setting, and Participants

The validated microsimulation model used for the decision analytical modeling study projected screening outcomes from 2025 to 2124 for a simulated cohort of 10 million individuals aged 50 years in 2025 and representative of a predominantly Hispanic or Latino patient population served by a Federally Qualified Health Center in Southern California. The simulated population had low adherence to first-step noninvasive testing (45%), second-step follow-up colonoscopy after an abnormal noninvasive test result (40%), and ongoing surveillance colonoscopy among patients with high-risk findings at follow-up colonoscopy (80%).

Exposures

Colorectal cancer screening strategies included no screening, an annual or biennial fecal immunochemical test, a triennial multitarget stool DNA test, and a triennial blood-based test. Using a blood-based test was assumed to increase first-step adherence by 17.5 percentage points.

Main Outcomes and Measures

Outcomes included colorectal cancer incidence and mortality, life-years gained and quality-adjusted life-years gained relative to no screening, costs, and net monetary benefit assuming a willingness to pay of $100 000 per quality-adjusted life-year gained.

Results

Under realistic adherence assumptions, a program of annual fecal immunochemical testing was the most effective and cost-effective strategy, yielding 121 life-years gained per 1000 screened individuals and a net monetary benefit of $5883 per person. Triennial blood testing was the least effective, yielding 23 life-years gained per 1000, and was not cost-effective, with a negative net monetary benefit. Annual fecal immunochemical testing with 45% first-step adherence and 80% adherence to follow-up and surveillance colonoscopy yielded greater benefit than triennial blood testing with perfect adherence (88 vs 77 life-years gained per 1000).

Conclusions and Relevance

This study suggests that in a federally qualified health care setting, prioritizing the convenience of blood tests over less costly and more effective existing stool-based tests could result in higher costs and worse population-level outcomes. Novel screening modalities should be carefully evaluated for performance in community settings before widespread adoption.

Automatic Quality Control System and Adenoma Detection Rates During Routine Colonoscopy: A Randomized Clinical Trial

Importance

High-quality colonoscopy reduces the risks of colorectal cancer by increasing the adenoma detection rate. Routine use of an automatic quality control system (AQCS) to assist in colorectal adenoma detection should be considered.

Objective

To evaluate the effect of an AQCS on the adenoma detection rate among colonoscopists who were moderate- and low-level detectors during routine colonoscopy.

Design, Setting, and Participants

This multicenter, single-blind, randomized clinical trial was conducted at 6 centers in China from August 1, 2021, to September 30, 2022. Data were analyzed from March 1 to June 30, 2023. Individuals aged 18 to 80 years were enrolled. Exclusion criteria were a history of inflammatory bowel disease, advanced colorectal cancer, and polyposis syndromes; known colorectal polyps without complete removal previously; a history of colorectal surgery; known stenosis or obstruction with contraindication for biopsy or prior failed colonoscopy; pregnancy or lactation; and refusal to participate. Intention-to-treat and per-protocol analysis was used.

Interventions

Standard colonoscopy or AQCS-assisted colonoscopy.

Main Outcomes and Measures

Adenoma detection rate.

Results

A total of 1254 participants (mean [SD] age, 51.21 [12.10] years; 674 [53.7%] male) were randomized (627 standard colonoscopy, 627 AQCS-assisted colonoscopy). Intention-to-treat analysis showed a significantly higher adenoma detection rate in the AQCS-assisted group vs standard colonoscopy group (32.7% vs 22.6%; relative risk [RR], 1.60; 95% CI, 1.23-2.09; P < .001). The adenoma detection rates were significantly higher in the AQCS group when considering pathology (nonadvanced adenomas, 30.1% vs 21.2%; RR, 1.52; 95% CI, 1.16-1.99; P = .002), and morphology (flat or sessile, 29.3% vs 20.4%, RR, 1.52; 95% CI, 1.16-2.00; P = .003). Use of AQCS significantly increased the adenoma detection rate of both the lower-level detectors (30.0% vs 20.0%; RR, 1.71; 95% CI, 1.24-2.35; P = .001) and the medium-level detectors (38.1% vs 27.7%; RR, 1.61; 95% CI, 1.07-2.43; P = .02). Similar increases were found for adenoma detection rates in the academic and nonacademic centers (academic: 29.3% vs 20.8%; RR, 1.58; 95% CI, 1.10-2.29; P = .01; nonacademic: 36.1% vs 24.5%; RR, 1.74; 95% CI, 1.23-2.46; P = .002). The number of adenomas per colonoscopy was significantly higher in the AQCS-assisted group (0.86 vs 0.48; RR, 1.50; 95% CI, 1.17-1.91; P = .001). The mean withdrawal time without intervention was slightly increased with AQCS assistance (6.78 vs 6.46 minutes; RR, 1.38; 95% CI, 1.26-1.52; P < .001). No serious adverse events were reported.

Conclusions and Relevance

In this randomized clinical trial, AQCS assistance during routine colonoscopy increased adenoma detection rates and several related polyp parameters compared with standard colonoscopy in the lower- and medium-level detectors in academic and nonacademic settings. Routine use of AQCS to assist in colorectal adenoma detection and quality improvement should be considered.

Trial Registration

ClinicalTrials.gov Identifier: NCT04901130.

Stool-Based Testing for Post-Polypectomy Colorectal Cancer Surveillance Safely Reduces Colonoscopies: The MOCCAS Study

BACKGROUND & AIMS

Colonoscopy-based surveillance to prevent colorectal cancer (CRC) causes substantial burden for patients and health care. Stool tests may help to reduce surveillance colonoscopies by limiting colonoscopies to individuals at increased risk of advanced neoplasia.

METHODS

This cross-sectional observational study included individuals aged 50-75 years with surveillance indication. Before bowel preparation, participants collected samples for a multitarget stool DNA test and 2 fecal immunochemical tests (FITs). Test accuracy was calculated for all surveillance indications. For the post-polypectomy indication only, which is the most common and is associated with a relatively low CRC risk, long-term impact of stool-based surveillance was evaluated with the Adenoma and Serrated Pathway to Colorectal Cancer (ASCCA) model. Stool-based strategies were simulated to tune each test's positivity threshold to obtain strategies at least as effective as colonoscopy surveillance.

RESULTS

There were 3453 individuals with results for all stool tests and colonoscopy; 2226 had previous polypectomy, 1003 had previous CRC, and 224 had a familial risk. Areas under the receiver operating characteristic curve for advanced neoplasia were 0.72 (95% CI, 0.69-0.75) for the multitarget stool DNA test, 0.61 (95% CI, 0.58-0.64) for the FIT OC-SENSOR (Eiken Chemical Co, Tokyo, Japan) and 0.59 (95% CI, 0.56-0.61) for the FIT FOB-Gold (Sentinel, Milan, Italy). Stool-based post-polypectomy surveillance strategies at least as effective as colonoscopy surveillance reduced the number of colonoscopies by 15%-41% and required 5.6-9.5 stool tests over a person's lifetime. Multitarget stool DNA-based surveillance was more costly than colonoscopy surveillance, whereas FIT-based surveillance saved costs.

CONCLUSIONS

This study found that stool-based post-polypectomy surveillance strategies can be safe and cost-effective, with potential to reduce the number of colonoscopies by up to 41%.

CLINICALTRIALS

gov, Number: NCT02715141.

Faecal Volatile Organic Compounds to Detect Colorectal Neoplasia in Lynch Syndrome-A Prospective Longitudinal Multicentre Study

BACKGROUND

Non-invasive biomarkers may reduce post-colonoscopy colorectal cancer (CRC) rates and colonoscopy overuse in Lynch syndrome. Unlike faecal immunochemical test (FIT), faecal volatile organic compounds (VOCs) may accurately detect both advanced and non-advanced colorectal neoplasia.

AIM

The aim of this study was to evaluate the potential of faecal VOCs-separately and with FIT-to guide optimal colonoscopy intervals in Lynch syndrome.

METHODS

Prospective longitudinal multicentre study in which individuals with Lynch syndrome collected faeces before and after high-quality surveillance colonoscopy. VOC-patterns were analysed using field asymmetric ion mobility spectrometry (FAIMS) and gas chromatography-ion mobility spectrometry (GC-IMS) followed by machine learning pipelines, and combined with FIT at 2.55 μg Hb/g faeces. Gas chromatography time-of-flight mass spectrometry analysed individual VOC abundance.

RESULTS

Among 200 included individuals (57% female, median 51 years), 62 had relevant neoplasia at colonoscopy: 3 CRC, 6 advanced adenoma (AA), 3 advanced serrated lesion (ASL), and 50 non-advanced adenoma (NAA). Respective sensitivity and negative predictive value for CRC and AA (and also ASL in case of FAIMS) were 100% and 100% using FAIMS (54% specificity), and 89% and 99% using GC-IMS (58% specificity). Respective sensitivity and specificity for any relevant neoplasia were 88% and 44% (FAIMS) and 84% and 28% (GC-IMS); accuracy did not significantly improve upon VOC-FIT. VOC-patterns differed before and after polypectomy (AUC 0.70). NAA showed decreased faecal abundance of butanal, 2-oxohexane, dimethyldisulphide and dimethyltrisulphide.

CONCLUSIONS

In Lynch syndrome, faecal VOCs may be a promising strategy for postponing colonoscopy and for follow-up after polypectomy. Our results serve as a stepping stone for large validation studies.

TRIAL REGISTRATION

NL8749.

Glutamic-pyruvic transaminase 1 deficiency-mediated metabolic reprogramming facilitates colorectal adenoma-carcinoma progression

The tumorigenesis of colorectal cancer (CRC) often follows the normal-adenoma-carcinoma (N-A-C) sequence. However, the molecular mechanisms underlying colorectal adenoma carcinogenesis remain largely unknown. Here, we analyzed transcriptomic profile changes in normal, advanced adenoma, and carcinoma tissues from patients with CRC, revealing that glutamic-pyruvic transaminase 1 (GPT1) in colorectal tissues was down-regulated during the N-A-C process and correlated with poor CRC prognosis. Mechanistically, GPT1 was transcriptionally activated by Krüppel-like factor 4 (KLF4). GPT1 reprogrammed metabolism and suppressed CRC tumorigenesis in cells and mouse models not only through enzyme-dependent α-ketoglutarate (α-KG) production and WNT signaling inhibition but also through enzyme-independent disruption of the folate cycle through binding with methylenetetrahydrofolate dehydrogenase 1-like (MTHFD1L). Furthermore, we identified poliumoside as a GPT1 activator that restrained CRC progression in cells, patient-derived CRC organoids, and patient-derived xenograft (PDX) models of CRC. Our study uncovers a role for GPT1 in CRC tumorigenesis and shows that poliumoside is a potential drug for the prevention and treatment of CRC.

Colorectal Cancer Incidence and Mortality After Negative Colonoscopy Screening Results

Importance

The current recommendation for a 10-year rescreening interval after a negative colonoscopy screening (NCS) result has been questioned, with some studies showing a persistently lower risk of colorectal cancer (CRC) after NCS results.

Objective

To examine long-term CRC incidence and mortality after NCS results (ie, no presence of CRC or polyps) and according to a risk score based on major demographic and lifestyle risk factors.

Design, Setting, and Participants

In this cohort study, 3 prospective US population-based cohorts from the Nurses' Health Study, Nurses' Health Study II, and Health Professionals Follow-up Study were followed up from 1988 and 1991 to 2020. Data from the National Health and Nutrition Examination Survey (NHANES) from the January 1, 2017, to December 31, 2018, cycle were used to compare the risk profile distribution with that of the general US population. Data analysis was performed from October 2023 to August 2024.

Exposures

Time-varying status of NCS results and risk score.

Main Outcomes and Measures

Cox proportional hazards regression was used to calculate hazard ratios (HRs) and 95% CIs for incidence and mortality of CRC.

Results

A total of 195 453 participants (median [IQR] age, 44 [37-56] years at baseline; 81% female) were followed up for a median (IQR) of 12 (6-20) years. Among 81 151 individuals with NCS results and 114 302 without endoscopy, 394 and 2229 CRC cases and 167 and 637 CRC deaths, respectively, were documented. Negative colonoscopy screening results were consistently associated with lower CRC incidence (HR, 0.51; 95% CI, 0.44-0.58) and mortality (HR, 0.56; 95% CI, 0.46-0.70) for 20 years. Among individuals with NCS results, those with an intermediate risk (scores, 6-7) and low risk (scores, 0-5) did not reach the 10-year cumulative incidence of CRC (0.78%) of the high-risk individuals (scores, 8-12) until 16 and 25 years after initial screening, respectively.

Conclusion and Relevance

These findings provide evidence for shared decision-making between patients and physicians to consider extending the rescreening intervals after an NCS result beyond the currently recommended 10 years, particularly for individuals with a low-risk profile. These results showed, as a proof of concepts, the importance of considering known CRC risk factors when making decisions for colonoscopy rescreening.

Colonic Polyp Study: Differences in Adenoma Characteristics Based on Colonoscopy History over 5-Year Follow-Up Period

Background: Timely detection and removal of colonic adenomas are critical for preventing colorectal cancer. Methods: This study analyzed differences in colonic adenoma characteristics based on colonoscopy history by reviewing the medical records of 14,029 patients who underwent colonoscopy between January and June 2020 across 40 primary medical institutions in Korea. Results: Adenoma and advanced neoplasia characteristics varied significantly with colonoscopy history (p < 0.05). In the first-time colonoscopy group, adenomas were more frequent in the sigmoid colon (S-colon) and rectum, with Is features and non-granular laterally spreading tumors. Advanced neoplasia was also more common in the S-colon and rectum, with Is and advanced-type features. In the <5-year group, adenomas were predominantly found in the transverse colon (T-colon) and descending colon (D-colon), with IIa and IIb features. Advanced neoplasia in this group was more frequent in the cecum and T-colon, with IIa and IIb features and laterally spreading tumors. In the ≥5-year group, adenomas were more commonly located in the ascending colon (A-colon) and cecum, with Ip features, while advanced neoplasia was more frequent in the A-colon and D-colon, also with Ip features. Conclusions: Although every segment of the colorectum should be carefully observed regardless of colonoscopy history, these findings suggest that prioritizing specific colonic segments for examination based on colonoscopy history may improve adenoma detection rates and reduce the incidence of colorectal cancer. However, further large-scale, prospective studies are needed to confirm these findings and support their application in clinical practice.

Pathology-Driven Automation to Improve Updating Documented Follow-Up Recommendations in the Electronic Health Record After Colonoscopy

INTRODUCTION

Failure to document colonoscopy follow-up needs postpolypectomy can lead to delayed detection of colorectal cancer (CRC). Automating the update of a unified follow-up date in the electronic health record (EHR) may increase the number of patients with guideline-concordant CRC follow-up screening.

METHODS

Prospective pre-post design study of an automated rules engine-based tool using colonoscopy pathology results to automate updates to documented CRC screening due dates was performed as an operational initiative, deployed enterprise-wide May 2023. Participants were aged 45-75 years who received a colonoscopy November 2022 to November 2023. Primary outcome measure is rate of updates to screening due dates and proportion with recommended follow-up < 10 years. Multivariable log-binomial regression was performed (relative risk, 95% confidence intervals).

RESULTS

Study population included 9,824 standard care and 19,340 intervention patients. Patients had a mean age of 58.6 ± 8.6 years and were 53.4% female, 69.6% non-Hispanic White, 13.5% non-Hispanic Black, 6.5% Asian, and 4.6% Hispanic. Postintervention, 46.7% of follow-up recommendations were updated by the rules engine. The proportion of patients with a 10-year default follow-up frequency significantly decreased (88.7%-42.8%, P < 0.001). The mean follow-up frequency decreased by 1.9 years (9.3-7.4 years, P < 0.001). Overall likelihood of an updated follow-up date significantly increased (relative risk 5.62, 95% confidence intervals: 5.30-5.95, P < 0.001).

DISCUSSION

An automated rules engine-based tool has the potential to increase the accuracy of colonoscopy follow-up dates recorded in patient EHR. The results emphasize the opportunity for more automated and integrated solutions for updating and maintaining EHR health maintenance activities.

General Versus Interventional Gastroenterologists: A Comparative Analysis of Follow-Up Outcomes After Endoscopic Mucosal Resection of Colorectal Polyps

Introduction Colorectal cancer (CRC) represents a major global health burden, significantly impacting mortality rates and healthcare systems worldwide. CRC screening through colonoscopy enables early detection and removal of precancerous polyps. While standard polypectomy suffices for small polyps, larger ones require endoscopic mucosal resection (EMR). Though post-EMR surveillance is crucial for preventing recurrence, it remains unclear whether follow-up by general gastroenterologists yields comparable outcomes to surveillance by interventional specialists. This distinction carries significant implications for resource allocation, particularly given the limited availability of interventional gastroenterologists whose expertise is needed for other complex procedures. Our study examines this unexplored question by comparing post-EMR surveillance outcomes between these provider groups. Methods We conducted a retrospective study at the Saint Louis Veterans Affairs (VA) Health Care System of patients presenting for follow-up of colorectal polyp EMR between January 2019 and December 2022. Pre-defined variables extracted from the electronic medical record system were then analyzed to discern significant differences between general and interventional gastroenterologists' outcomes. The primary outcome includes the rate of biopsy of scars after EMR between both groups. Additional outcomes include the number of polyps detected, detection of residual tissue at the EMR site, EMR site recurrence requiring polypectomy and mode of polypectomy, recommended surveillance interval suggested by the endoscopist, and the pathology of the EMR site biopsy. Results A total of 59 (N = 59) patients (median age: 67, mean age: 66.5 ± 6.6 years) met the inclusion criteria of our study. General gastroenterologists were more likely to biopsy the EMR site compared to interventional gastroenterologists (65% vs. 40%, p = 0.047). There was no difference in overall pathology detected when comparing general and interventional gastroenterologists (p = 0.074). While no EMR site biopsies were obtained in 16 patients (27.1%), there were no differences in the pathology of patients undergoing biopsy of the scar. Additionally, no significant differences were found in the Boston Bowel Preparation Score, number of polyps detected, detection of residual tissue at the EMR site, EMR site recurrence requiring polypectomy, or recommended surveillance interval. Conclusion Our study provides evidence that the outcomes of post-EMR follow-up are largely comparable between general and interventional gastroenterologists. Although general gastroenterologists exhibit higher rates of EMR site biopsy, the associated pathology shows no significant difference.

Predictors of No-Shows After an Endoscopic Mucosal Resection in Veterans: A Retrospective Analysis

Introduction Endoscopic mucosal resection (EMR) is a common intervention for large colorectal polyps, but its long-term success depends heavily on post-procedure surveillance to detect recurrence. Despite the critical importance of follow-up appointments, some patients fail to attend these crucial visits. This study aims to identify demographic, clinical, and socioeconomic factors that predict missed follow-up appointments after EMR. By understanding which patients are at the highest risk for non-compliance, we can develop targeted strategies to improve follow-up adherence and optimize long-term outcomes in this population. Methods We conducted a single-center retrospective study at the Saint Louis Veterans Affairs Healthcare System of patients presenting for colon polyp EMR between January 2019 and December 2022. The primary outcome was the no-show rates for the scheduled patient endoscopic follow-up among patients who underwent EMR. A predictive model was then constructed to yield adjusted odds ratios and their prospective 95% confidence intervals. Results A total of 69 patients met the inclusion criteria. Fifty-nine patients followed up within the recommended interval. Ten patients failed to attend their follow-up appointments and were labeled as no-shows. The predictors of no-shows with their adjusted odds ratios and 95% confidence intervals in descending order included previous history of one or more no-shows (3.8, 1.7-8.5, p = 0.002), recommended follow-up interval greater than six months (3.5, 1.1-12.5, p = 0.04), psychiatric comorbidities (2.8, 1.7-4.6, p = 0.002), and history of substance use (2.7, 1.8-6, p = 0.03). Conclusions In patients undergoing EMR, our study identified several risk factors for follow-up non-compliance, including previous no-show history, substance use disorder, and psychiatric comorbidities. These findings suggest that targeted interventions for high-risk patients may improve follow-up adherence. While longer follow-up intervals (>6 months) were associated with increased no-show rates, modifying established surveillance guidelines would require dedicated studies evaluating the safety and efficacy of alternative follow-up schedules.

Association of late eating with colorectal adenomas: a cross-sectional study

PURPOSE

Colorectal cancer (CRC) is linked to lifestyle exposures. However, changes in the CRC rates among younger populations remain poorly understood and suggest the existence of yet unidentified factor(s) that may contribute to colon carcinogenesis. Here, we investigated the potential role of time of eating in the risk of pre-cancerous colonic neoplasms (tubular adenoma: TA).

METHODS

We enrolled 663 participants undergoing screening colonoscopies. Data on food timing, dietary intake, sleep/wake patterns, and chronotype were collected through structured questionnaires. Late eating was defined as the consumption of food or snack within a 3-hour window of sleep onset for at least four days a week. Pathology reports confirmed the histology of colonic polyps, and adenomas were further classified into risk categories.

RESULTS

A total of 644 patients met criteria for our study. There were 270 (42.2%) participants classified as late eaters. Compared to non-late eaters, the odds of TA were higher in late eaters (OR = 1.46, 95% CI = 1.05-2.03, p = 0.023), an association which was strengthened after adjusting for multiple confounders (OR 1.98, 95% CI 1.19-3.28, p = 0.008). Late eating remained an independent risk factor for high-risk as well as multiple TAs.

CONCLUSION

This study proposes late eating as a risk factor for colon tubular adenomas and underscores the potential role of less studied forms of circadian disruption imposed by time of eating in the development of colon neoplastic formation.

Surveillance after Endoscopic Resection for Colorectal Tumors: A Comprehensive Review

BACKGROUND

The goal of surveillance after the endoscopic resection of colorectal tumors is to reduce colorectal cancer (CRC) incidence and mortality. Considering the effective use of the limited endoscopic capacity and the cost of surveillance, it is desirable to develop a surveillance program that is as minimal as possible. In Europe (European Society of Gastrointestinal Endoscopy [ESGE]) and the USA (Multi-Society Task Force [MSTF]), after the results of the National Polyp Study (NPS) were established, guidelines were developed that stratified risk based on initial endoscopy, and surveillance programs for each risk group were proposed. More than 10 years later, the "colonoscopy screening and surveillance guidelines" were developed with the basic principle of "aiming for zero CRC deaths during surveillance, bowel preservation, and emphasis on patient quality of life" as the guideline principles in Japan.

SUMMARY

Randomized controlled trials to evaluate the appropriate surveillance intervals after endoscopic resection of colorectal tumors, the NPS, the Nottingham Study, and the Japan Polyp Study (JPS), are summarized. The ESGE, USMSTF, and Japanese guidelines compared low-risk adenoma, high-risk adenoma, advanced neoplasia, piecemeal resection, and serrated lesions by category.

KEY MESSAGES

Surveillance guidelines based on risk stratification were developed in Japan. Guidelines are meaningful only when they are effectively utilized in clinical practice. They must also be revised based on new evidence. It is hoped that new knowledge will be accumulated, especially in Japan, on topics that are currently lacking.

BACKGROUND

The goal of surveillance after the endoscopic resection of colorectal tumors is to reduce colorectal cancer (CRC) incidence and mortality. Considering the effective use of the limited endoscopic capacity and the cost of surveillance, it is desirable to develop a surveillance program that is as minimal as possible. In Europe (European Society of Gastrointestinal Endoscopy [ESGE]) and the USA (Multi-Society Task Force [MSTF]), after the results of the National Polyp Study (NPS) were established, guidelines were developed that stratified risk based on initial endoscopy, and surveillance programs for each risk group were proposed. More than 10 years later, the "colonoscopy screening and surveillance guidelines" were developed with the basic principle of "aiming for zero CRC deaths during surveillance, bowel preservation, and emphasis on patient quality of life" as the guideline principles in Japan.

SUMMARY

Randomized controlled trials to evaluate the appropriate surveillance intervals after endoscopic resection of colorectal tumors, the NPS, the Nottingham Study, and the Japan Polyp Study (JPS), are summarized. The ESGE, USMSTF, and Japanese guidelines compared low-risk adenoma, high-risk adenoma, advanced neoplasia, piecemeal resection, and serrated lesions by category.

KEY MESSAGES

Surveillance guidelines based on risk stratification were developed in Japan. Guidelines are meaningful only when they are effectively utilized in clinical practice. They must also be revised based on new evidence. It is hoped that new knowledge will be accumulated, especially in Japan, on topics that are currently lacking.

Using Computer-aided Optical Diagnosis and Expert Review to Evaluate Colorectal Polyps Diagnosed as Normal Mucosa in Pathology

Pathological assessment of colorectal polyps is considered the current reference standard for histologic diagnosis. About 10% of polyps sent to the pathology lab are returned with the diagnosis of mucosal folds, mucosal prolapse, or normal mucosa.1,2 Two recent publications have indicated that disagreements between endoscopic optical diagnosis and the subsequent pathological diagnoses might be due to misdiagnosis in pathology.3,4 We were therefore interested in re-evaluating pathology-based diagnosis of "mucosal polyps" using expert endoscopists and computer-assisted diagnosis (CADx) evaluation.

Computer-aided diagnosis for the resect-and-discard strategy for colorectal polyps: a systematic review and meta-analysis

BACKGROUND

The resect-and-discard strategy allows endoscopists to replace post-polypectomy pathology with real-time prediction of polyp histology during colonoscopy (optical diagnosis). We aimed to investigate the benefits and harms of implementing computer-aided diagnosis (CADx) for polyp pathology into the resect-and-discard strategy.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, and Scopus from database inception to June 5, 2024, without language restrictions, for diagnostic accuracy studies that assessed the performance of real-time CADx systems, compared with histology, for the optical diagnosis of diminutive polyps (≤5 mm) in the entire colon. We synthesised data for three strategies: CADx-alone, CADx-unassisted, and CADx-assisted; when the endoscopist was involved in the optical diagnosis, we synthesised data exclusively from diagnoses for which confidence in the prediction was reported as high. The primary outcomes were the proportion of polyps that would have avoided pathological assessment (ie, the proportion optically diagnosed with high confidence; main benefit) and the proportion of polyps incorrectly predicted due to false positives and false negatives (main harm), directly compared between CADx-assisted and CADx-unassisted strategies. We used DerSimonian and Laird's random-effects model to calculate all outcomes. We used Higgins I2 to assess heterogeneity, the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate certainty, and funnel plots and Egger's test to examine publication bias. This study is registered with PROSPERO, CRD42024508440.

FINDINGS

We found 1019 studies, of which 11 (7400 diminutive polyps, 3769 patients, and 185 endoscopists) were included in the final meta-analysis. Three studies (1817 patients and 4086 polyps [2148 neoplastic and 1938 non-neoplastic]) provided data to directly compare the primary outcome measures between the CADx-unassisted and CADx-assisted strategies. We found no significant difference between the CADx-assisted and CADx-unassisted strategies for the proportion of polyps that would have avoided pathological assessment (90% [88-93], 3653 [89·4%] of 4086 polyps diagnosed with high confidence vs 90% [95% CI 85-94], 3588 [87·8%] of 4086 polyps diagnosed with high confidence; risk ratio 1·01 [95% CI 0·99-1·04; I2=53·49%; low-certainty evidence; Egger's test p=0·18). The proportion of incorrectly predicted polyps was lower with the CADx-assisted strategy than with the CADx-unassisted strategy (12% [95% CI 7-17], 523 [14·3%] of 3653 polyps incorrectly predicted with a CADx-assisted strategy vs 13% [6-20], 582 [16·2%] of 3588 polyps incorrectly diagnosed with a CADx-unassisted strategy; risk ratio 0·88 [95% CI 0·79-0·98]; I2=0·00%; low-certainty evidence; Egger's test p=0·18).

INTERPRETATION

CADx did not produce benefit nor harm for the resect-and-discard strategy, questioning its value in clinical practice. Improving the accuracy and explainability of CADx is desired.

FUNDING

European Commission (Horizon Europe), the Japan Society of Promotion of Science, and Associazione Italiana per la Ricerca sul Cancro.

Association of Endoscopist Colonoscopy Quality Measures With Follow-Up Colonoscopy Outcomes After Positive Stool Tests (Multitarget Stool DNA or Fecal Immunochemical Test): Retrospective Cross-Sectional Analysis of Data From the New Hampshire Colonoscopy Registry

INTRODUCTION

Negative colonoscopies following positive stool tests could result from stool test characteristics or from the quality of endoscopist performance. We used New Hampshire Colonoscopy Registry data to examine the association between endoscopist detection rates and polyp yield in colonoscopies performed for positive fecal immunochemical test (FIT) or multitarget stool DNA (mt-sDNA) test to evaluate the degree to which positive stool tests followed by negative colonoscopy ("false positives") vary with endoscopist quality. In addition, we investigated the frequency of significant polyps in the subgroup of highest quality colonoscopies following positive stool tests.

METHODS

We compared the frequencies of negative colonoscopies and of specific polyps following positive stool tests across quartiles of endoscopist adenoma detection rate (ADR) and clinically significant serrated polyp detection rate (CSSDR).

RESULTS

Our sample included 864 mt-sDNA+ and 497 FIT+ patients. We found a significantly lower frequency of negative colonoscopies following positive stool tests among endoscopists with higher ADR and CSSDR, particularly in the 2 highest quartiles. In addition, detection of any adenoma after a positive stool test for endoscopists in the fourth ADR quartile was 63.3% (FIT+) and 62.8% (mt-sDNA+). Among endoscopists in the fourth CSSDR quartile, sessile serrated lesions were found in 29.2% of examinations following a positive mt-sDNA and in 13.5% following FIT+ examinations.

DISCUSSION

The frequency of negative colonoscopies after positive stool tests was significantly higher in examinations performed by endoscopists with low ADR and CSSDR. Our results also suggest a benchmark target of at least 40% for ADR in patients with mt-sDNA+ or FIT+ tests and 20% for sessile serrated lesions in mt-sDNA+ patients.

Prediction of metachronous advanced colorectal neoplasia by KRAS mutation in polyps

BACKGROUND

The potential of molecular markers in the removed polys as reliable predictors of metachronous lesions is still uncertain.

AIM

Our aim was to evaluate the role of somatic mutations in KRAS in polyps of patients with high-risk adenomas to predict the risk of advanced polyps or colorectal cancer (CRC) within 3 years.

METHODS

A total of 518 patients were prospectively enrolled. The included patients had adenomas ≥10 mm, high-grade dysplasia, villous component or ≥3 more adenomas at baseline and were scheduled to undergo surveillance colonoscopy at 3 years ± 6 months. Somatic KRAS mutation was performed on 1189 polyps collected from these patients. At surveillance, advanced lesions were defined as adenomas with a size of ≥10 mm. High-grade dysplasia or villous component, serrated polyps ≥10 mm or with dysplasia or CRC.

RESULTS

At baseline, 81 patients (15.6%) had KRAS mutations in at least one polyp. Patients with KRAS mutated polyps had more frequent villous histological lesions and size ≥20 mm. In the multivariate analysis, adjusted for age and sex, only age (odds ratios [OR], 1.06; 95% confidence interval [CI], 1.02-1.09; p < 0.001), ≥5 adenomas (OR, 3.92; 95% CI, 1.96-7.82), and KRAS mutation (OR, 2.54; 95% CI, 1.48-4.34; p < 0.01) were independently associated with the development of advanced lesions at surveillance.

CONCLUSIONS

Our results show that, in patients with high-risk adenomas, the presence of somatic mutations in KRAS is an independent risk factor for the development of advanced metachronous polyps.

Polyp size is associated with colorectal cancer death across histologic polyp subtypes: a retrospective study of a screening colonoscopy registry

BACKGROUND

Surveillance colonoscopy after polyps have been detected at screening aims to reduce the risk for subsequent colorectal cancer, so-called post-colonoscopy colorectal cancer (PCCRC). Inconsistencies exist as to whether the risk should be stratified by histologic subtype. We aimed to compare the risk for PCCRC mortality in screening participants with sessile serrated lesions (SSLs)/traditional serrated adenomas (TSAs), hyperplastic polyps (HPPs), or conventional adenomas.

METHODS

Screening colonoscopy registry data were linked to death registry data between 2010 and 2022. We assessed the association of PCCRC death after a diagnosis of SSL/TSA, conventional adenoma, or HPP by Cox regression, and stratified by polyp size ≥10 and <10 mm.

RESULTS

383,801 participants were included in the analysis. There were 1490 HPPs ≥10 mm (2.6%), compared with 1853 SSL/TSAs (19.6%) and 10,960 conventional adenomas (12.9%). When adjusted for polyp location, the association of polyp size ≥10 mm with PCCRC death was of similar magnitude in participants with conventional adenomas (hazard ratio [HR] 3.68, 95%CI 2.49-5.44), SSL/TSAs (HR 2.55, 95%CI 1.13-5.72), and HPPs (HR 5.01, 95%CI 2.45-10.22). Participants with HPPs mostly died of tumors in the distal colon (54.1%; n = 20), while participants with SSL/TSAs more frequently died of proximal tumors (33.3%; n = 3).

CONCLUSIONS

Across all histologic types, participants with polyps ≥10 mm had at least a two-fold increase in the likelihood of PCCRC death compared with those with polyps <10 mm. These data suggest that size, rather than histologic subtype, should be a determinant for risk stratification after screening colonoscopy.