Applying the ESGE guideline risk-profiles for surveillance as outcome parameter in a FIT-based colorectal cancer screening program

Aims The European Society of Gastrointestinal Endoscopy (ESGE) recommends using risk profiles to determine the colonoscopy surveillance interval after polypectomy [1]. This new risk-profile strategy will also be implemented within the Dutch colorectal cancer (CRC) screening program. Currently, the screening program monitors the FIT’s positive predictive value (PPV) based on the outcome of advanced neoplasia. Changing the definition from advanced neoplasia to high-risk profiles alters the definition of a relevant lesion, which might affect the PPV. Therefore, we aim to assess the impact of using the ESGE risk-profiles as outcome parameter of a FIT-based CRC screening program on PPV and surveillance.

Methods We analysed all persons with a positive FIT (≥ 47 µg Hb/g feces) followed by colonoscopy in the Dutch CRC screening program from 2019-2022. The PPV was calculated by dividing relevant colonoscopy lesions, by all colonoscopies performed. Relevant lesions were defined in three ways; i) advanced neoplasia, ii) CRC and high-risk polyps (high-risk adenoma and high-risk serrated polyps) and iii) CRC and high-risk profile (high-risk polyps and≥5 adenomas) [2]. Significant differences between PPV were assessed by a X² test. Surveillance intervals were categorized according to the old and new surveillance guideline based on endoscopy and pathology reports. The old surveillance guideline used a score table in which, adenoma count, location, villous type, and size were used to determine surveillance intervals at 3-5 years or return to screening in 10 years. The new ESGE guideline defines a high-risk profile as high-risk adenoma, high-risk serrated polyp, or≥5 adenomas, all requiring 3-year surveillance. A low-risk profile requires no surveillance [3].

Results 218,109 persons with a positive FIT underwent colonoscopy between 2019-2022. The PPV significantly increased from 32.7% for advanced neoplasia to 34.4% for CRC and high-risk polyps. The highest PPV of 36.8% was noted for CRC and high-risk profiles. Based on the old guideline, 51.2% of the persons would require surveillance (16.0% 3 year surveillance and 35.2% 5 year surveillance) compared to 32.2% in the new guideline (all requiring 3 year surveillance). The increase in the 3 year interval, from 16.0% to 32.2%, results from 723 persons initially assigned to a 10-year screening interval and 34,451 persons assigned to a 5-year surveillance interval. In contrast, 32 persons had initially a 3-year interval but shifted to a 10-year screening interval due to the new guideline.

Conclusions Applying the new ESGE surveillance guideline risk profiles in FIT-based CRC screening program will increase the PPV of FIT. High-risk profiles will have the most impact on PPV, which is the result of considering≥5 adenomas as a relevant lesion. Using high-risk profiles will reduce overall colonoscopy surveillance by 18.9%, although the 3 year surveillance interval will be doubled.

Publication History

Article published online:
27 March 2025

• References

• 1 Federatie Medisch Specialisten (FMS) richtlijn colorectal carcinoom [Internet] cited November 2024, available from https://richtlijnendatabase.nl/richtlijn/coloscopie_surveillance/startpagina.html
• 2 Nederlandse Vereniging van maag-darm-leverartsen (NVMDL) Nederlandse coloscopie surveillance richtlijn 2013 [Internet] cited November 2024 https://www.mdl.nl/files/richlijnen/Richtlijn_Coloscopie_Surveillance_definitief_2013.pdf
• 3 Hassan C, Antonelli G, Dumonceau JM, Regula J, Bretthauer M, Chaussade S. et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2020. Vol. 52, Endoscopy. Georg Thieme Verlag; 2020. p. 687-700