Surveillance for One or Two Small Adenomas: Low Risk Is Really Low Risk.

​The optimal timing for postpolypectomy surveillance for low-risk adenomas, defined as 1-2 small tubular adenomas, has remained a challenge for clinicians and guideline developers over the past 4 decades. From the 1970s to the 1990s, it was common practice for clinicians to recommend annual surveillance for even a small adenoma (ie, <10 mm), because of the perceived knowledge that all adenomas were premalignant. In 1993, the National Polyp Study helped to provide much needed evidence for the timing of postpolypectomy surveillance by showing there was no difference in the risk of finding an advanced adenoma at 1 and 3 years after the baseline colonoscopy versus 3 years alone. As a result, a 3-year surveillance interval after removal of any adenoma was suggested for adoption. When the first surveillance guideline was issued in 1997, the recommended follow-up interval was 5 years for patients with one small tubular adenoma. In 2003, the United States Multi-Society Task Force (USMSTF) on Colorectal Cancer and a panel of various medical specialists updated the guideline and recommended that patients with 1-2 small tubular adenomas undergo surveillance in 5 years,owing in large part to the low risk for advanced adenomas on follow-up colonoscopy 3-5 years later. In 2006, the USMSTF broadened the recommended surveillance interval to 5-10 years for patients with 1-2 small tubular adenomas. This recommendation was based mainly on the low incidence of subsequent advanced adenomas and colorectal cancer (CRC) in observational cohort studies after removal of a low-risk adenoma on the baseline examination. More recently, the USMSTF updated their 2006 surveillance guideline in 2012 again supported a surveillance interval of 5-10 years after removal of a low-risk adenoma. However, despite the evidence and decades of guideline recommendations, studies have consistently shown that clinicians are bringing back patients with low-risk adenomas for their postpolypectomy surveillance earlier than the recommended minimum of 5 years. This suggests an overuse of surveillance colonoscopy, which already accounts for >25% of colonoscopies performed annually in the United States.

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