Faculty Bibliography

BACKGROUND:An association between higher adenoma detection rate (ADR) at index screening colonoscopy and lower risk of metachronous advanced neoplasia (AN, defined as colorectal cancer (CRC) or advanced adenoma (AA)) has been reported. However, the relationship between ADR at both index and surveillance colonoscopy and subsequent AN is unknown. We examined the association between ADR and withdrawal time (WT) at index and surveillance colonoscopy and risk of metachronous AN at surveillance colonoscopy. METHODS:We used GIQuIC, a repository of colonoscopies across the US. Each patient has a unique ID at a participating site. Endoscopist NPI are associated with each exam. We included patients with two colonoscopies at least 3 years apart (index and surveillance) between 2011 and 2022 and calculated the ADR and average WT for the endoscopist performing the index and surveillance colonoscopies respectively. We built a multivariable logistic regression model with metachronous AN as the outcome and ADR and WT as independent variables, controlling for patient age, sex and race. RESULTS:We included 768,274 patients and 3,425 endoscopists. Mean patient age was 61 years and 48% were male; 66% were White and 3% were Hispanic. Indication for index colonoscopy were screening (43.4%), surveillance (39.0%) and diagnostic (17.6%). ADR quartiles were ≤29.7%, >29.7%-37.2%, >37.2%-45.0% and >45%. WT quartiles were ≤7.1 min, >7.1 -8.2 min, >8.2-9.7min, >9.7min. Advanced neoplasia detection was lowest when low ADR endoscopists performed both index and surveillance exams (5.4%, Table 1) and high ADR index exams were followed by low ADR surveillance exams (4.0%). Compared to low ADR endoscopists for both index and surveillance exams, advanced was significantly higher when both exams performed by a high ADR endoscopist (AA 7.4%; OR for AN 1.10(1.05-1.16)) or low ADR index exams were followed by high ADR surveillance exams (AA 13.3%; OR for AN 1.448 (1.37-1.51)). Compared to short WT endoscopists for both exams (AA 7.2%; CRC 0.3%), advanced neoplasia detection was higher when both exams were performed by a long WT endoscopist or short WT index exams were followed by long WT surveillance exams (AA 7.0% p=.53 and 9.9%, P<0.001) but similar CRC detection of 0.2% and 0.2% (p 0.14). Other factors associated with finding of metachronous advanced neoplasia were older age (>=76 years vs 45-55 years OR 1.64; 95% CI 1.48, 1.82), male sex (Male vs female OR 1.15; 95% CI 1.10-1.19), White race compared to non-white (OR1.10; 95% CI 1.06, 1.14), 7-10 years between exams compared to 3-5 years between exams (OR 1.24; 95% CI 1.11, 1.37), indication of surveillance vs. screening for the index exam (OR 1.1.7; 95% CI 1.13, 1.22), advanced adenoma or sessile serrated lesion finding on the index exam (OR 2.08; 95% CI 1.97, 21.9 and OR 1.23; 95% CI 1.16, 1.30 respectively). CONCLUSION/CONCLUSIONS:Our findings show endoscopist ADR and WT for both index and surveillance colonoscopy are associated with risk of metachronous neoplasia, including CRC. Future studies on metachronous neoplasia should include both sets of quality indicators.

BACKGROUND AND AIMS/OBJECTIVE:Colorectal cancer screening reduces mortality, yet uptake remains suboptimal. Various interventions aim to improve screening rates, but their comparative effectiveness is unclear. We aim to evaluate the effectiveness of colorectal cancer screening uptake interventions using a systematic review and network meta-analysis. METHODS:We analyzed data from 76 randomized clinical trials across eight intervention strategies: patient navigation, mailed FIT outreach, educational multimedia, reminder-only, choice-based outreach, colonoscopy outreach, multistep, and usual care. Network meta-analysis compared interventions using risk ratios (RRs) and 95% confidence intervals (CIs). P-scores and rankograms assessed intervention rankings. Risk of bias was assessed, and certainty of evidence was graded using the GRADE framework. RESULTS:Patient navigation (RR 1.58, 95% CI 1.23-2.02; P-score 0.81) and mailed FIT outreach (RR 1.36, 95% CI 1.07-1.74; P-score 0.79) were the most effective strategies, significantly outperforming usual care. Educational multimedia (RR 1.27, 95% CI 0.91-1.78) and reminder-only interventions (RR 1.24, 95% CI 0.98-1.57) showed modest effects. Choice-based outreach and colonoscopy outreach were not significantly more effective than usual care. Mailed FIT outreach was superior to colonoscopy outreach (RR 1.35, 95% CI 1.11-1.63), and patient navigation outperformed reminder-only interventions (RR 1.48, 95% CI 1.14-1.94). In low baseline uptake settings (<30%), mailed FIT outreach was most effective (RR 3.12, 95% CI 1.70-5.71), while educational multimedia performed best in higher uptake populations (≥30%) and in recent studies (2021-2024). Majority of studies were at low risk of bias while the certainty of evidence mostly ranged from moderate to low. CONCLUSION/CONCLUSIONS:Patient navigation and mailed FIT outreach are the most effective strategies for increasing colorectal cancer screening uptake, particularly in low baseline uptake populations. Educational multimedia shows promise in recent years and high baseline uptake settings, offering a scalable alternative.

BACKGROUND AND AIMS/OBJECTIVE:Growing evidence suggests that the gut microbiome plays a role in carcinogenesis for early-onset colorectal cancer (EOCRC). The novel Ring Finger Protein 213 (RNF213) gene has broad antimicrobial properties. Our study aimed to compare RNF213 mutation rates in EOCRC and late-onset colorectal cancer using data from the cBioPortal for Cancer Genomics. METHODS:All participants from the cBioPortal with CRC samples that profiled the RNF213 gene were included. Multivariable logistic regression was used to assess the association between EOCRC and primary tumor RNF213 mutation. Cox proportional hazards models were used to evaluate the influence of RNF213 mutation on all-cause mortality risk. All tests were two-sided. RESULTS:OR 1.61, 95% CI 0.72, 3.22). There was no significant difference in all-cause mortality risk by RNF213 mutation status. CONCLUSIONS:Primary tumor mutations in exon 29 of the RNF213 gene are associated with significantly increased odds of EOCRC diagnosis in a multicohort sample of participants with CRC. Future studies of germline and precancerous RNF213 mutations are needed to elucidate its possible role in EOCRC tumorigenesis.

Despite advances in endoscopic techniques, many colorectal surgeries in the United States are still performed for non-malignant colorectal polyps (NMCRPs). This study evaluated trends, demographic variations, and outcomes of surgeries for NMCRPs among all colorectal surgeries over the past decade. Using the TriNetX nationwide database, we identified adults (≥ 18 years of age) who underwent colectomy or proctectomy for NMCRPs or colorectal cancer between 2013 and 2023. We evaluated the proportion of surgeries performed for NMCRPs, stratified by demographic factors, and compared postoperative adverse events (AEs) between NMCRP and colorectal cancer surgeries. Among 136,721 surgeries, 52,480 (38.4%) were for NMCRPs. The proportion of NMCRP surgeries decreased from 59% in 2013 to 33% in 2023, with the most significant decline between 2013 and 2016. Black individuals showed the highest decrease. Compared with colorectal cancer surgeries, NMCRP surgeries were associated with significantly lower risks of wound, infectious, urinary, pulmonary, gastrointestinal, and cardiac AEs. Although the proportion of NMCRP surgeries has declined, ongoing efforts in education and training are needed to further reduce unnecessary surgeries and improve patient outcomes.

BACKGROUND:The American College of Gastroenterology (ACG) assembled a multidisciplinary task force to evaluate the current state and future direction of artificial intelligence (AI) in gastroenterology, hepatology, and endoscopy leading to the development of consensus-based recommendations for responsible AI integration in clinical practice. METHODS:A total of 32 subject-matter experts and 12 industry partners, representing diverse practice settings and expertise, conducted subgroup literature reviews across five key areas (endoscopy, practice management clinical applications, training and education, IBD and liver disease, ethics and equity). Draft statements were developed and rated on a 5-point Likert scale using a modified Delphi process. A consensus was set at ≥70% combined agreement. Non-consensus items were revised and re-voted electronically. RESULTS:A total of 43 statements, 40 (93%) reached consensus in round 1 and the remaining 3 achieved consensus after round 2. Evidence supports computer-aided detection (CADe) improving adenoma detection rate and miss rate in controlled studies, with mixed "real-world" impact and insufficient long-term outcomes (e.g., interval colon cancer rate). Recommendations emphasize thorough validation and reduction of bias via heterogeneous datasets. Outside endoscopy, ambient AI scribes, NLP-enabled coding, workflow optimization, and prior authorization support show potential. Training recommendations endorse a structured AI curriculum while preserving independent procedural competence to avoid "deskilling". In IBD and hepatology, AI could help improve diagnostic accuracy, help predict risk for disease progression, and help guide therapy. Equity, governance, and reimbursement statements call for chain-of-custody data protections, specialty-society oversight, and payment models that reward quality and cost reduction. CONCLUSIONS:This consensus outlines how AI can augment rather than replace clinical expertise while promoting safety, transparency, interoperability, and equity. Priorities include pragmatic and prospective trials, multi-institutional data-sharing consortia, bias mitigation, and workforce training to enable trustworthy and clinically impactful AI adoption in GI, liver, and endoscopy care.

BACKGROUND & AIMS/OBJECTIVE:This study assessed the economic and health impact of colorectal cancer (CRC) screening programs for average-risk individuals aged 45 years and older. METHODS:A 10-year Markov model simulated disease progression, comparing multitarget stool RNA test (mt-sRNA, ColoSense), two mt-sDNA tests (Cologuard and Cologuard Plus), a blood-based test (cfDNA, Shield), and a fecal immunochemical test (FIT). Clinical inputs leveraged age-weighted sensitivity and specificity from independent studies. Outcomes were compared with a colonoscopy-based program and no screening. Model calibration and validation used previously reported Cancer Intervention Surveillance Modeling Network (CISNET) models. RESULTS:Among molecular tests, mt-sRNA detected the most advanced adenomas, referred the most individuals to surveillance, and prevented the highest number of CRC cases and deaths. At real-world adherence of 60%, mt-sRNA reduced CRC cases and deaths by 1% and 14% compared with FIT; by 21% and 19% compared with mt-sDNA; by 28% and 23% compared with mt-sDNA+; and by 80% and 86% compared with cfDNA. For all adherence levels, FIT ($25/test) was the most cost-effective strategy. For triennial molecular tests ($509/test), mt-sRNA was the most cost-effective strategy. Relative to the mt-sRNA program, the cost to prevent a CRC case was 30% (mt-sDNA), 45% (mt-sDNA+), and 642% (cfDNA) more expensive. Relative to the mt-sRNA program, the cost to prevent a CRC death was 30% (mt-sDNA), 41% (mt-sDNA+), and 1040% (cfDNA) more expensive. CONCLUSIONS:FIT was the most cost-effective strategy for preventing CRC cases and deaths. At real-world adherence of 60%, mt-sRNA demonstrated the greatest clinical benefit and was more cost-effective than other molecular strategies.

BACKGROUND AND AIMS/OBJECTIVE:Most colorectal cancer (CRC) screening tests, including fecal immunochemical (FIT) and multitarget stool DNA tests, require patients to scrape a stool sample at home before mailing it to a central lab. This requirement not only deters screening adherence but can also introduce risks of human error, environmental exposure, and transit-related issues. The multitarget stool RNA test (mt-sRNA), which comprises a FIT component and an RNA molecular component, is the only FDA-approved stool-based test for the detection of both CRC and advanced adenomas (AA) that does not require patients to perform an at-home FIT. Instead, trained technicians complete the FIT in the laboratory after the sample is received. This study evaluates the comparability of at-home and in-laboratory FIT in relation to mt-sRNA test performance. METHODS:To assess comparability between the 2 FIT methods, banked residual stool samples from the mt-sRNA test pivotal clinical trial (CRC-PREVENT) were used. As part of clinical trial requirements, subjects were required to collect a stool sample using the mt-sRNA collection kit and complete an at-home FIT swab before shipping the sample back to the laboratory. Patients were subsequently required to complete a screening colonoscopy. Residual stool was sampled using the in-laboratory FIT. Both FIT collection methods (at-home and in-laboratory) were analyzed identically. FIT results were compared with each other and with colonoscopy, to assess concordance, sensitivity, and specificity. RESULTS:A total of 1079 stool samples were tested using both at-home and in-laboratory FIT methods. Overall concordance was 93%. Among 20 CRC cases, the sensitivity for both methods was 75% (n=15). For 231 AA cases, sensitivity for the at-home and in-laboratory FIT was 33% and 38%, respectively. Positive percent agreement (PPA) for colorectal neoplasia was 87%. Among 791 subjects with negative findings, specificity for the at-home and in-laboratory FIT was 94% and 95%, respectively. For subjects with negative findings, the negative percent agreement (NPA) was 98%. When incorporating the in-laboratory FIT into the mt-sRNA test, method-calibrated CRC and AA sensitivities were 94% and 48%, respectively. Method-calibrated specificity for no lesions on colonoscopy was 90%. CONCLUSIONS:Our findings suggest that in-laboratory FIT performance may enhance the diagnostic accuracy of the mt-sRNA test. The in-laboratory method may also reduce inadequate sampling and improve patient ease of use.