Re-evaluating post-polypectomy surveillance: The role of non-invasive modalities in colorectal cancer prevention

Post-polypectomy surveillance is a cornerstone of colorectal cancer (CRC) prevention, yet current reliance on colonoscopy poses challenges related to capacity, patient burden, and adherence. Amid growing interest in non-invasive strategies, this review evaluates the diagnostic performance, clinical applicability, and limitations of emerging alternatives, including faecal immunochemical testing (FIT), multitarget stool DNA (mt-sDNA), CT colonography (CTC), circulating tumour DNA (ctDNA), and colon capsule endoscopy (CCE), in the context of post-polypectomy surveillance. While FIT remains widely endorsed for low-risk populations, its limited sensitivity for flat adenomas and serrated lesions constrains its utility. mt-sDNA and CTC offer incremental improvements in detection but face cost-effectiveness, false-positive, and guideline limitations in surveillance. ctDNA holds promise for recurrence monitoring in high-risk CRC but remains investigational for adenoma surveillance. Evidence for CCE as a triage tool is emerging, though concerns persist regarding incomplete examinations, cost, and residual risk. Importantly, substantial heterogeneity in surveillance guidelines and suboptimal real-world adherence complicate evaluation and implementation of these modalities. Integration of molecular biomarkers and risk-adaptive strategies may support more personalised follow-up. However, robust comparative effectiveness studies that account for system-level and behavioural factors are essential to guide appropriate adoption. Non-invasive tools remain complementary, not yet replacements, for colonoscopy in post-polypectomy care.