Toward optimizing the use of limited colonoscopy resource

10.1055/a-2751-2956

Colonoscopy plays a pivotal role in reducing colorectal cancer (CRC) incidence and mortality across various settings, including screening, diagnosis, and surveillance. To achieve this goal, ensuring high-quality colonoscopy procedures is essential. In addition, given that colonoscopy resources are limited, it is crucial to establish strategies that prioritize these resources for individuals who truly require the procedure. In this context, CRC risk stratification of the target population represents a reasonable and necessary step to consider.

„The PROMOTE model’s simplicity, based on easily accessible factors, makes it highly practical for real-world implementation.“

Risk stratification has been extensively explored in CRC screening. Since the target population for CRC screening includes many low-risk individuals who may not require colonoscopy, strategies to prioritize colonoscopy resources and reduce unnecessary procedures are essential. The fecal immunochemical test (FIT), a widely used global screening tool, is one of the most established methods for efficiently allocating colonoscopies to high-risk individuals. Beyond FIT, a variety of risk-stratification tools have been explored, ranging from simple clinical risk scores to advanced emerging technologies. A number of risk scores based on individual characteristics such as age, sex, family history of CRC, and smoking status have been proposed for CRC screening [1]. Furthermore, combined approaches utilizing both FIT and these risk scores have been suggested to further enhance screening efficiency [2]. Despite the appeal of more detailed risk-stratified strategies incorporating multiple factors and modalities, the ease of implementation in real-world practice remains a critical consideration. In this regard, a risk-stratification strategy based solely on FIT concentration, beyond the binary positive/negative classification, is currently gaining attention. Even within the negative range, FIT concentration has been shown to predict future CRC and advanced colorectal neoplasia incidence, and the approach of determining screening intervals based on FIT concentration is currently under evaluation [3] [4] [5].

Risk stratification has also been explored outside of CRC screening programs. For diagnostic colonoscopies in symptomatic patients, several approaches based on expert consensus, such as the criteria of the European Panel on Appropriateness of Gastrointestinal Endoscopy (EPAGE)-II and of the American Society for Gastrointestinal Endoscopy (ASGE), have been proposed to ensure appropriate indications for colonoscopy. More recently, the Colonoscopy Appropriateness Prioritization (CAP) criteria have been introduced, that classify patients into “urgent,” “deferrable,” and “nonurgent” categories, based on their indication. However, the clinical validity and practical usefulness of these criteria remain to be established. In this issue of Endoscopy, Frazzoni et al. report the development of the PROMOTE model to predict and stratify CRC risk, incorporating the CAP criteria along with factors of patient age and history of colonoscopy within the last 10 years, to determine colonoscopy prioritization [6]. This model was validated temporally and geographically through a prospective observational study of adults undergoing colonoscopy outside CRC screening programs across 19 Italian centers. The results demonstrate that this new model has favorable predictive ability and outperformed the EPAGE-II and ASGE criteria. The number needed to scope to detect one CRC was 8–9 in the high-risk group of the model and 67–71 in the low-risk group across validation cohorts. This suggests that the model has the potential to contribute to the efficient triage of patients for colonoscopy and lead to more efficient use of colonoscopy resources. The PROMOTE model’s simplicity, based on easily accessible factors, makes it highly practical for real-world implementation.

Despite high expectations for this model, several concerns need to be addressed before widespread adoption. First, the target population in this study is at higher risk for CRC compared with the general population, and therefore especial caution is warranted to avoid overlooking CRC cases. In this context, given the demonstrated utility of FIT even for symptomatic patients [7], combining FIT results with the model may enhance its predictive ability, and this area warrants further research. Furthermore, it is important to note that this study was conducted in Italy only, which limits its generalizability. Therefore, international validation of the model is needed before its widespread implementation.

Toward the optimal allocation of limited colonoscopy resources, it is also important to optimize post-polypectomy surveillance intervals and reduce the number of unnecessary colonoscopies for the low-risk surveillance population. The post-polypectomy surveillance guidelines have been updated to address this issue, and several studies are ongoing that focus on these challenges, such as the European Polyp Surveillance (EPoS) trials [8].

Strategies for risk stratification to prioritize colonoscopy procedures across screening, diagnosis, and surveillance are highly anticipated as a means to optimize the use of limited colonoscopy resources, as discussed above. However, for broader real-world implementation, further evaluations are necessary. In the course of these evaluations, while the predictive abilities of risk-stratification tools are undoubtedly crucial, equal attention must be given to the ease and feasibility of their integration into routine clinical practice.

Publikationsverlauf

Artikel online veröffentlicht:
17. Dezember 2025

• References

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