For patients with high-risk adenomas, initiating surveillance five years after polyp removal is not inferior to initiation at three years, according to a study published in the Sept. 17 issue of the New England Journal of Medicine.
Rodrigo Jover, M.D., Ph.D., from Hospital General Universitario Dr. Balmis in Alicante, Spain, and colleagues conducted an ongoing noninferiority trial in eight European countries involving patients with high-risk adenomas who were randomly assigned to undergo a first colonoscopy at five years after polyp removal or at three years; current guidelines recommend surveillance at three years. A total of 10,799 patients underwent randomization: 5,398 and 5,401 were assigned to the five- and three-year groups, respectively.
At an interim analysis conducted after 5.5 years of follow-up, the researchers found that the five-year cumulative incidence of colorectal cancer was 0.77 and 0.82 percent with less frequent and more frequent surveillance, respectively; the upper boundary of the 99.12 percent confidence interval was 0.68 percent, meeting the noninferiority criterion. There was no substantial difference between the groups in the distribution of cancer stage at diagnosis. Overall, five patients died of colorectal cancer: three and two (0.06 and 0.04 percent) in the five- and three-year groups, respectively.
“These interim findings make one point clear already: surveillance policy must be determined not by habit or by fear of doing too little, but by evidence of what benefits patients,” Aasma Shaukat, M.D., M.P.H., from the New York University Grossman School of Medicine in New York City, and Theodore R. Levin, M.D., from Kaiser Permanente in Pleasanton, California, write in an accompanying editorial.
Several authors disclosed ties to the biopharmaceutical industry.
The research does not indicate that every patient with a previous adenoma should automatically wait five years for a colonoscopy. Surveillance intervals depend on several factors, including the number, size, and pathology of previously removed polyps, as well as the quality and completeness of the prior colonoscopy.
The findings support more individualized surveillance strategies and possibly reduce unnecessary procedures for some patients. With this in mind, clinicians should continue following established surveillance recommendations until guidelines incorporate new evidence.
Research shows that Black adults experience a higher incidence of colorectal cancer and have the highest mortality among major racial and ethnic groups. The U.S. Preventive Services Task Force (USPSTF) recommends colorectal cancer screening for everyone at age 45, including Black adults. However, the Task Force strongly encourages clinicians to ensure Black patients receive recommended screening, follow-up, and treatment. It also encourages systems that deliver high-quality care across the continuum of screening and treatment, with special attention given to Black communities, who are disproportionately burdened by colorectal cancer.
The new findings raise an important distinction between appropriately extending surveillance for patients who meet criteria and simply losing patients to follow-up.
For Black patients, the focus should be on ensuring surveillance recommendations are clearly communicated, documented, and completed when indicated — not assuming that race alone warrants a different surveillance interval.
The findings reveal that surveillance after adenoma removal is not the same as average-risk colorectal cancer screening. Patients with prior adenomas are outside the average-risk population addressed by routine screening recommendations.
After removing an adenoma, clinicians must document and communicate the recommended surveillance interval. Systems that can support the recall or reminder processes may help prevent patients from falling through the cracks.
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