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Examining the whole large bowel with a flexible camera; polyps found on the way are removed (polypectomy), which prevents most bowel cancers.
The only screening test that both detects and prevents cancer: removing adenomas cuts colorectal cancer incidence and mortality by half or more (National Polyp Study, NordICC). It is the confirmatory test after a positive stool test (FIT) or blood test, and the surveillance tool after polyp removal or resection. Quality is measured by adenoma detection rate and caecal intubation; AI polyp detection raises the former. Bowel preparation and sedation are the main deterrents to uptake.
A colonoscopy probably does reduce bowel cancer risk for the person who has it, but a programme that offers colonoscopy achieves much less if most people decline. Programmes based on stool tests with high uptake may deliver as much population benefit at lower cost and risk.
It links the molecular route to the practical failure mode: interval cancers after a clear colonoscopy are disproportionately serrated, so detection quality is a molecular problem as much as a technical one.
It is the reason colonoscopy quality standards now count sessile serrated lesion detection separately, and the reason a right-sided, BRAF-mutant, MSI-high cancer is read as serrated in origin rather than as an odd adenoma.
The clinical proof of Vogelstein's sequence: interrupting the adenoma-carcinoma pathway with a snare prevents the cancer, which is why colonoscopy is the only screening test that both detects and prevents.
The paper that made the adenoma detection rate the central quality measure of every screening endoscopy service, and the reason endoscopist-level auditing is a condition of accreditation.
Shares UK Flexible Sigmoidoscopy Screening Trial, Adenoma detection rate, Screening uptake, Interval cancer.
Shares Screening uptake, Interval cancer, NHS bowel cancer screening programme, Surveillance intervals after polypectomy.
Shares Adenoma detection rate, Quality indicators for colonoscopy and the risk of interval cancer, Capsule endoscopy (PillCam, EndoCapsule, CapsoCam), UK gap: match endoscopy capacity and quality to the faecal immunochemical test thresholds the NHS has already set.
Shares Screening uptake, Interval cancer, NHS bowel cancer screening programme, Colorectal cancer.
Shares UK gap: shorten the route to diagnosis for patients below the screening age, where the rise in incidence is, Treat screening uptake, not test sensitivity, as the thing to optimise, and settle the age extension with a trial rather than a model, Early-onset colorectal cancer (under 50), Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation.
Shares NordICC: inviting people to a screening colonoscopy reduced bowel cancer, but less than expected, Treat screening uptake, not test sensitivity, as the thing to optimise, and settle the age extension with a trial rather than a model, Early-onset colorectal cancer (under 50), Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation.
Shares Lynch syndrome testing after bowel cancer, and what it means for the family, Serrated pathway, Lynch syndrome-associated colorectal cancer, Colorectal cancer.
Shares EMR and ESD (endoscopic mucosal resection, endoscopic submucosal dissection), Capsule endoscopy (PillCam, EndoCapsule, CapsoCam), Endoscopic resection (EMR / ESD).