Balancing benefit and burden: rethinking post-polypectomy colonoscopy surveillance strategies

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. This Viewpoint critically examines the limitations underlying current post-colonoscopy surveillance strategies, including reliance on historical data with inadequate collection of quality indicators, insufficient focus on the absolute risk of colorectal cancer, and potential misclassification of patients' risk. We argue that these limitations might have led to suboptimal allocation of surveillance intensity. We advocate for a shift towards a more comprehensive risk-stratified framework, in which surveillance decisions are guided by absolute colorectal cancer risk thresholds and could incorporate less invasive triage approaches for lower-risk individuals. Overall, we propose rethinking post-polypectomy surveillance to better align clinical practice with contemporary evidence with the goal of improving patient outcomes while minimising unnecessary interventions and health-care burden.