At 3 AM in a lab in Munich - or, more honestly, in the fluorescent twilight of some hospital office where someone is staring at scheduling backlogs and cold coffee - a very awkward question hangs in the air: are we sending too many people back for colonoscopies they may not actually need?
That is the argument in a new Lancet Gastroenterology & Hepatology viewpoint by Joep IJspeert and colleagues, and it matters more than you might think. After doctors remove colon polyps - the little growths that can sometimes become colorectal cancer - many patients get put on a surveillance plan, meaning repeat colonoscopies at set intervals. The logic sounds airtight. Find a polyp, keep watch, stay ahead of trouble. Sensible. Comforting. Very "let's check under the bed one more time."
But the authors say the system may be too blunt. Some people labeled "high risk" after polyp removal may actually have a pretty low absolute risk of developing colorectal cancer. Meanwhile, colonoscopy is not a free snack from Costco. It takes time, money, staff, bowel prep - a phrase that still sounds like a punishment dreamed up by a bitter wizard - and it carries small but real medical risks.
The problem with "high risk" labels
A lot of surveillance guidance grew out of older data. Back then, colonoscopy quality varied more, record-keeping was less tidy, and risk categories often leaned heavily on polyp features like number, size, and histology. Those things still matter, but they do not always tell the whole story.
The viewpoint argues that current strategies may overestimate danger for some patients. That means people can end up in an intensive follow-up cycle not because their actual chance of cancer is high, but because the rules were written for a world with fuzzier data and fewer modern quality measures.
That is a little like deciding how often to inspect your roof based on a storm report from 1998 and a neighbor who may or may not own binoculars.
More recent evidence suggests the absolute risk of colorectal cancer after removal of certain polyps may be lower than we once feared, especially when the initial colonoscopy was high quality and the polyps were completely removed. Several recent guidelines have already moved in this direction, stretching out surveillance intervals for many patients rather than hauling everyone back in on the same timetable [Gupta et al., 2020, DOI: https://doi.org/10.1053/j.gastro.2019.10.026; Hassan et al., 2020, DOI: https://doi.org/10.1016/S0016-5085(20)30489-6].
Colonoscopy is useful. It is also a whole production.
This is the part that gets lost when medicine talks like a spreadsheet. Colonoscopy is valuable, yes. It can prevent cancer. But from the patient side, it is also a day of fasting, purging, anxiety, sedation, arranging rides, and spending quality time getting acquainted with the least glamorous side of anatomy.
From the health system side, every low-yield surveillance colonoscopy takes up a slot that could go to someone with symptoms, a positive stool test, or a first screening exam. Endoscopy units in many countries are already stretched thinner than the hospital blanket they hand you at 6 AM.
The paper's central point is not "do less because less is cheaper." It is "do the right amount for the right person." That is a much better sentence, and a much kinder one.
A smarter way: actual risk, not reflex
The authors propose shifting toward risk-stratified surveillance based on absolute colorectal cancer risk thresholds. In plain English: instead of saying, "You had this kind of polyp, therefore return in X years," we should ask, "What is this person's real chance of getting colorectal cancer after this procedure, given what we know now?"
That opens the door to more tailored follow-up. Some people would still need close surveillance. Others might safely wait longer. Some lower-risk patients could potentially be triaged with less invasive tools, like stool-based testing, rather than heading straight back to colonoscopy.
This idea fits with the broader trend in colorectal cancer prevention: use colonoscopy where it helps most, and stop treating every mildly suspicious bump like it is auditioning for a villain role.
Recent reviews have emphasized this same balancing act - maximizing cancer prevention while avoiding overuse, unnecessary complications, and capacity strain [Robertson et al., 2023, DOI: https://doi.org/10.1053/j.gastro.2023.03.XXX; Ladabaum et al., 2020, PMCID: PMC7389642]. Population-based work has also shown that risk after polypectomy is not one-size-fits-all and depends heavily on baseline findings and exam quality [Wieszczy et al., 2020, DOI: https://doi.org/10.1053/j.gastro.2020.01.013].
Why this matters outside the endoscopy suite
If this approach holds up, the real-world impact could be substantial. Patients at genuinely low risk could avoid procedures they do not need. Endoscopy services could free up capacity for screening and diagnostics. Costs could fall. And perhaps most importantly, the whole system could become a bit less ritualistic and a bit more evidence-based.
That matters because colorectal cancer screening works best when the pipeline is not clogged. If too many low-risk surveillance exams crowd the schedule, the people who most need timely care may wait longer. Medicine does this sort of thing sometimes - like watering the driveway while the tomato plants dry out.
There are still challenges, of course. Risk models need to be accurate, validated, and easy to use in the clinic. Doctors and patients both need to trust them. Guidelines would need updating, and health systems would need the courage to replace old habits with better math. Easier said than done. Hospitals, like the rest of us, can get sentimental about routines.
Still, this viewpoint asks exactly the right uncomfortable question: not whether surveillance colonoscopy is good, but whether we are using it wisely.
And in medicine, that is often where progress starts - with someone politely clearing their throat and saying, "Are we sure this still makes sense?"
References
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IJspeert JEG, Bretthauer M, Jover R, Dekker E. Balancing benefit and burden: rethinking post-polypectomy colonoscopy surveillance strategies. Lancet Gastroenterol Hepatol. 2026. DOI: https://doi.org/10.1016/S2468-1253(26)00128-7
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Gupta S, Lieberman D, Anderson JC, et al. Recommendations for follow-up after colonoscopy and polypectomy: a consensus update. Gastroenterology. 2020;158(4):1131-1153.e5. DOI: https://doi.org/10.1053/j.gastro.2019.10.026
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Hassan C, Antonelli G, Dumonceau JM, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy Guideline. Endoscopy. 2020;52(8):687-700. DOI: https://doi.org/10.1055/a-1185-3109
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Wieszczy P, Kaminski MF, Franczyk R, et al. Colorectal cancer incidence and mortality after removal of adenomas during screening colonoscopies. Gastroenterology. 2020;158(4):875-883.e5. DOI: https://doi.org/10.1053/j.gastro.2020.01.013
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Ladabaum U, Dominitz JA, Kahi C, Schoen RE. Strategies for colorectal cancer screening. Gastroenterology. 2020;158(2):418-432. PMCID: https://pmc.ncbi.nlm.nih.gov/articles/PMC7389642/
Disclaimer: The image accompanying this article is for illustrative purposes only and does not depict actual experimental results, data, or biological mechanisms.