Recommendations

Sr.­no.

Recommendations

QoE

1

No adenoma or polyps: There is now stronger evidence to support the 10-year interval after negative findings on baseline colonoscopy for average-risk individuals, assuming that the baseline colon examination is complete with a good bowel preparation.
Individuals with a first-degree relative (FDR with CRC or HRA have an increased lifetime risk of developing CRC, particularly if the FDR was younger than 60 years at the time of diagnosis. If colonoscopy is performed and the finding is normal, the recommended interval for repeat screening should be 5 years if the FDR was younger than 60 years and 10 years if the FDR was 60 years or older.

Mod

Evidence for Recommendation 1

2

No adenomas; distal small (<10 mm) hyperplastic polyps: Prior and current evidence suggests that distal HPs <10 mm are benign and nonneoplastic. If the most advanced lesions at baseline colonoscopy are distal HPs <10 mm, the interval for colonoscopic follow-up should be 10 years.

Mod

Evidence for Recommendation 2

3

1—2 tubular adenomas <10 mm: Data published since 2006 endorse the assessment that patients with 1—2 tubular adenomas with low-grade dysplasia <10 mm represent a low-risk group. Three new studies suggest that this group may have only a small, nonsignificant increase in risk of advanced neoplasia within 5 years compared with individuals with no baseline neoplasia.
The evidence supports a surveillance interval of longer than 5 years for most patients. We recognize that quality of the bowel preparation may result in a less than optimal examination in some portions of the colon. In a recent report, when the bowel preparation was inadequate, the miss rates for adenoma and advanced adenoma at 1 year were 35% and 36%, respectively. Factors associated with finding an adenoma on subsequent examination included lack of cecal intubation (OR, 3.62; 95% CI, 2.50— 5.24) and finding a polyp at the baseline examination (OR, 1.55; 95% CI, 1.17—2.07). In these circumstances, a 5-year interval might still be prudent.

Mod

Evidence for Recommendation 3

4

3—10 adenomas: The new information from the VA study and the NCI Pooling Project support the previous recommendation that patients with 3 or more adenomas have a level of risk for advanced neoplasia similar to other patients with advanced neoplasia (adenoma >10 mm, adenoma with HGD There are insufficient new data to support a change in the prior recommendation.

Mod (if polyp ≥6 mm)
Low (if polyp <6 mm)

Evidence for Recommendation 4

5

>10 adenomas: There is no basis for changing the recommendation to consider follow-up in less than 3 years after a baseline colonoscopy.

Mod-High

Evidence for Recommendation 5

6

One or more tubular adenomas ≥10 mm: The new information provides additional data showing that patients with one or more adenomas ≥10 mm have an increased risk of advanced neoplasia during surveillance compared with those with no neoplasia or small (<10 mm) adenomas. There is no basis for changing the recommended 3-year surveillance interval. This recommendation assumes that the examination was of high quality and complete removal of neoplastic tissue occurred at baseline. This group represents a small proportion of all patients with adenomas. If there is question about complete removal (ie, piecemeal resection), early follow-up colonoscopy is warranted.

High

Evidence for Recommendation 6

7

One or more adenomas with villous features of any size: The new information provides additional data showing that patients with one or more adenomas with villous histology have an increased risk of advanced neoplasia during surveillance compared with those with no neoplasia or small (<10 mm) tubular adenomas. There is no basis for changing the recommended 3-year surveillance interval.

Mod

Evidence for Recommendation 7

8

One or more adenomas with HGD: The presence of an adenoma with HGD is an important risk factor for development of advanced neoplasia and CRC during surveillance. There is no basis for changing the recommended 3-year surveillance interval.

Mod

Evidence for Recommendation 8

9

Serrated polyps: Prior surveillance guidelines did not comment on surveillance intervals if proximal serrated polyps are found at baseline colonoscopy. There are no longitudinal studies available on which to base surveillance intervals after resection. Our recommendation is based on low-quality evidence and will require updating when new data are available. The current evidence suggests that size (>10 mm), histology (a sessile serrated polyp is a more significant lesion than an HP; a sessile serrated polyp with cytological dysplasia is more advanced than a sessile serrated polyp without dysplasia), and location (proximal to the sigmoid colon) are risk factors that might be associated with higher risk of CRC. A sessile serrated polyp ≥10 mm and a sessile serrated polyp with cytological dysplasia should be managed like HRA (Table 1). Serrated polyps that are <10 mm and do not have cytological dysplasia may have lower risk and can be managed like LRA.

Low

Evidence for Recommendation 9

QoE: Quality of Evidence

High: High-Quality Evidence

Mod: Moderate-Quality Evidence

Mod-High: Moderate-High Quality Evidence

Low: Low-Quality Evidence

CRC: Colorectal cancer

HRA: High-risk adenoma

HPs: Hyperplastic polyps

FDR: First-degree relative

OR: Odds ratio

NCI: National Cancer Institute

HGD: High-grade dysplasia

CI: Confidence interval