Gastroenterology · Medical Literature
[Viewpoint] Balancing benefit and burden: rethinking post-polypectomy colonoscopy surveillance strategies
Abstract
Post-polypectomy colonoscopy surveillance is widely implemented to reduce colorectal cancer incidence and mortality, yet increasing evidence raises concerns about whether current strategies are optimally balanced in terms of benefit, burden, and resource use. At least some individuals currently classified as being high risk for post-polypectomy colorectal cancer might actually have a low absolute risk, suggesting that surveillance might be overused in this group of patients. At the same time, colonoscopy surveillance imposes considerable burden at the patient, health-care system, and societal levels, including procedural risks, costs, and pressure on endoscopy capacity.
Clinical relevance
Are current post-polypectomy colonoscopy surveillance strategies optimally balanced with respect to benefit, procedural burden, resource utilization, and absolute colorectal cancer risk — and should existing risk classification systems and surveillance intensity be rethought? __SNAPSHOT__ {"studyDesign":"Viewpoint / Expert opinion and narrative synthesis (not a primary research study or systematic review with meta-analysis)","setting":"Multi-institutional, international expert perspective; authors affiliated with the Netherlands Cancer Institute–Antoni van Leeuwenhoek (Amsterdam), University of Oslo / Oslo University Hospital, Hospital General Universitario Dr Balmis (Alicante, Spain), and Amsterdam University Medical Center (Amsterdam, Netherlands); produced on behalf of the Dutch Colonoscopy Surveillance Working Group","sampleSize":"Not applicable (expert opinion/narrative synthesis; no primary patient cohort enrolled)","population":"Individuals undergoing post-polypectomy colonoscopy surveillance following resection of colorectal polyps, with particular focus on patients currently classified as high risk under existing risk stratification systems","intervention":"Critical appraisal of current post-polypectomy colonoscopy surveillance strategies, including risk classification systems and surveillance intensity","comparator":"Not applicable (no formal comparator arm; viewpoint contrasts current practice against emerging evidence on absolute colorectal cancer risk and burden considerations)","primaryOutcome":"Not applicable (viewpoint article; no prespecified primary endpoint). The central argument concerns whether surveillance is overused in patients classified as high risk who may have a low absolute colorectal cancer risk, and whether colonoscopy surveillance burden — procedural risks, costs, endoscopy capacity — is adequately weighted against expected benefit","followUp":"Not applicable","fundingSource":"Not reported"}
Key findings
This is a Viewpoint article and does not report original primary data, effect sizes, p-values, confidence intervals, or NNT/NNH values. The authors argue, on the basis of accumulating observational and epidemiological evidence cited within the article, that at least some individuals currently classified as high risk for post-polypectomy colorectal cancer (CRC) may in fact carry a low absolute CRC risk, implying that current surveillance is overused in this subgroup. Simultaneously, they highlight that colonoscopy surveillance imposes substantial burden at the patient, health-care system, and societal levels — encompassing procedural risks, costs, and pressure on endoscopy capacity. No new quantitative findings are presented. Referenced supporting literature includes evidence that polyps ≥10 mm without other high-risk features may carry a similarly low post-colonoscopy CRC risk as individuals without polyps (Endoscopy 2026; 58:376–383), and data suggesting that endoscopist performance may modulate post-colonoscopy CRC risk independently of polyp characteristics. The authors propose rethinking post-polypectomy surveillance to better align clinical practice with contemporary evidence, aiming to improve patient outcomes while minimising unnecessary interventions and healthcare burden. No adverse event data specific to this article are reported beyond the general reference to procedural risks inherent to colonoscopy.
Practice implications
This Viewpoint from an experienced international group raises clinically important questions about whether binary high/low-risk stratification in post-polypectomy surveillance adequately captures absolute CRC risk — and whether the accumulated burden of surveillance colonoscopy (procedural complications, costs, and endoscopy capacity strain) has been sufficiently incorporated into guideline development. The authors do not present new primary data; the piece synthesizes existing evidence to argue for a conceptual reorientation. As such, no causal claims can be made, and no direct changes to individual patient management are established by this article alone. The argument is particularly relevant for the subset of patients classified as 'high risk' based on features such as polyp size ≥10 mm in isolation, who may not have elevated absolute CRC risk compared to the general population. The viewpoint is less directly applicable to patients with clearly elevated absolute risk (e.g., high-grade dysplasia, multiple advanced adenomas, serrated polyposis). Critically, because only an abstract and referenced citation list are publicly available, the full scope of evidence synthesis, proposed alternative strategies, and nuance of the argument cannot be fully assessed from publicly accessible text. Practice change based on this article alone would be premature; this piece should be read as a call for evidence re-evaluation and guideline reconsideration rather than as actionable guidance. __LIMITATIONS__ 1. Article type: This is a Viewpoint/expert opinion, the lowest level of evidence in the evidence hierarchy; it is not a systematic review, meta-analysis, or primary clinical trial. 2. No original data: No primary patient-level data, statistical analyses, effect sizes, or confidence intervals are generated or reported. 3. Selective evidence citation: Narrative synthesis in viewpoint articles is inherently susceptible to selective citation and framing bias; no formal GRADE or PRISMA methodology is applied. 4. Generalizability: The working group is predominantly European/Dutch; surveillance systems, endoscopy capacity constraints, and population-level CRC risk may differ substantially in other healthcare contexts (e.g., US, Asia, lower-income settings). 5. Risk classification heterogeneity: 'High risk' is operationalized differently across international guidelines (ESGE 2020, BSG 2020, US Multi-Society Task Force 2020), limiting the universal applicability of the critique. 6. Funding not reported: Potential conflicts of interest cannot be fully assessed without access to the full article's disclosure section. 7. Abstract-only access: Only the abstract and citation list are publicly accessible; the full argument, proposed alternative frameworks, and supporting evidence tables cannot be independently verified from the available text. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ This expert Viewpoint in The Lancet Gastroenterology & Hepatology argues that current post-polypectomy surveillance strategies may overuse colonoscopy in patients classified as high risk who carry a low absolute CRC risk, while underweighting the procedural, economic, and capacity burden of surveillance. No primary data are presented, and this article does not by itself justify changes to individual surveillance practice. Clinicians and guideline committees should treat this as a well-positioned call for re-evaluation of risk stratification frameworks and surveillance thresholds, ideally to be followed by rigorous prospective trials or updated evidence syntheses.