New risk stratification after colorectal polypectomy reduces burden of surveillance without increasing mortality

Abstract

Background: The 2020 postpolypectomy surveillance guideline update of European Society for Gastrointestinal Endoscopy defines a more restrictive group of individuals in need for surveillance 3 years after colonoscopy.

Aim: The aim of this cohort study was to validate the new guideline recommendation.

Methods: Based on a national quality assurance program, we compared the 2020 risk group definition with the previous 2013 recommendations for their strength of association with (1) colorectal cancer death, and (2) all-cause death.

Results: A total of 265,608 screening colonoscopies were included in the study. Mean age was 61.1 years (SD ±9.0), and 50.6% were women. During a mean follow-up of 59.3 months (SD ±35.0), 170 CRC deaths and 7723 deaths of any cause were identified. 62.4% of colonoscopies were negative and 4.9% were assigned to surveillance after 3 years according to the 2020 guidelines versus 10.4% following the 2013 guidelines, which corresponds to a relative reduction in colonoscopies by 47%. The strength of association with CRC mortality was markedly higher with the 2020 surveillance group as compared to the 2013 guidelines (HR 2.56, 95% CI 1.62-4.03 vs. HR 1.73, 95% CI 1.13-2.62), while the magnitude of association with CRC mortality for low risk individuals was lower (HR 1.17, 95% CI 0.83-1.63 vs. 1.25, 95% CI 0.88-1.76).

Conclusions: Adherence to the updated guidelines reduces the burden of surveillance colonoscopies by 47% while preserving the efficacy of surveillance in preventing CRC mortality.

Keywords: CRC; cancer; colonoscopy; colorectal cancer; mortality; polypectomy; risk-stratification; screening; surveillance.

FIGURE 1

Patient flow

FIGURE 2

Colorectal cancer mortality after colonoscopy stratified by surveillance groups according to the 2020 Guidelines compared to the 2013 Guidelines. No adenoma: individuals with negative colonoscopy (no conventional adenoma or serrated polyp). Surveillance: individuals with at least one adenoma ≥10 mm or with high‐grade dysplasia, or ≥5 adenomas, or any serrated polyp ≥10 mm or with dysplasia. No surveillance: individuals with 1–4 adenomas <10 mm with low‐grade dysplasia, or any serrated polyp <10 mm without dysplasia. High‐risk: individuals with at least one adenoma ≥10 mm, or high‐grade dysplasia, or tubulovillous or villous histology, or serrated lesions ≥10 mm or with dysplasia. Low‐risk: individuals with 1–2 tubular adenomas <10 mm and low‐grade dysplasia, or serrated lesions <10 mm without dysplasia

FIGURE 3

Hazard ratio for colorectal cancer mortality stratified by surveillance groups according to the 2020 Guidelines compared to the 2013 Guidelines. Age and sex adjusted for all individuals, and sex adjusted according to age group. Surveillance: individuals with at least one adenoma ≥10 mm or with high‐grade dysplasia, or ≥5 adenomas, or any serrated polyp ≥10 mm or with dysplasia. No surveillance: individuals with 1–4 adenomas <10 mm with low‐grade dysplasia, or any serrated polyp <10 mm without dysplasia. High‐risk: individuals with at least one adenoma ≥10 mm, or high‐grade dysplasia, or tubulovillous or villous histology, or serrated lesions ≥10 mm or with dysplasia. Low‐risk: individuals with 1–2 tubular adenomas <10 mm and low‐grade dysplasia, or serrated lesions <10 mm without dysplasia

FIGURE 4

Colorectal cancer mortality after colonoscopy stratified by risk group according to the 2020 Guideline compared to the proposed limited surveillance group for countries with limited resources. No adenoma: individuals with negative colonoscopy (no conventional adenoma or serrated polyp). Surveillance: individuals with at least one adenoma ≥10 mm or with high‐grade dysplasia, or ≥5 adenomas, or any serrated polyp ≥10 mm or with dysplasia. No surveillance: individuals with 1–4 adenomas <10 mm with low‐grade dysplasia, or any serrated polyp <10 mm without dysplasia. High‐risk: individuals with at least one adenoma ≥10 mm, or high‐grade dysplasia, or tubulovillous or villous histology, or serrated lesions ≥10 mm or with dysplasia. Low‐risk: individuals with 1–2 tubular adenomas <10 mm and low‐grade dysplasia, or serrated lesions <10 mm without dysplasia