Negative Screening Colonoscopy Research Articles

Negative screening colonoscopy and long-term colorectal cancer risk—is it time to extend the screening interval?

Negative screening colonoscopy and long-term colorectal cancer risk—is it time to extend the screening interval?

Prevalence of Colorectal Neoplasia 10 or More Years After a Negative Screening Colonoscopy in 120 000 Repeated Screening Colonoscopies

Screening colonoscopy to prevent and early detect colorectal cancer is recommended to be repeated in 10-year intervals, which goes along with high demands of capacities and costs. Evidence of findings at screening colonoscopies conducted 10 or more years after a negative colonoscopy result is sparse, and it remains unclear whether screening colonoscopy intervals could possibly be prolonged. To assess the prevalence of advanced colorectal neoplasms (ADNs) at least 10 years after a negative screening colonoscopy in a very large cohort of repeated screening colonoscopy participants in Germany. This registry-based cross-sectional study on screening colonoscopy findings reported to the German screening colonoscopy registry during January 2013 to December 2019 included data on screening colonoscopies that were offered to the German general population 55 years or older since 2002; virtually all screening colonoscopies among individuals covered by Statutory Health Insurance (approximately 90% of eligible adults) are reported to the national registry. A total of 120 298 repeat screening colonoscopy participants 65 years or older were identified who had a previous negative screening colonoscopy at least 10 years prior. The findings were compared with all screening colonoscopies conducted at 65 years or older during the same period (1.25 million). The data were analyzed from March to July 2022. Prevalence of colorectal cancers and ADNs (advanced adenomas and cancers). Of 120 298 participants, 72 349 (60.1%) were women. Prevalence of ADN was 3.6% and 5.2% among women and men 10 years after a negative screening colonoscopy and gradually increased to 4.9% and 6.6%, respectively, among those who had a negative colonoscopy 14 years or longer prior compared with 7.1% and 11.6% among all screening colonoscopies. Sex-specific and age-specific prevalence of ADNs at repeated colonoscopies conducted 10 or more years after a negative colonoscopy were consistently at least 40% lower among women than among men, lower at younger vs older ages, and much lower than among all screening colonoscopies (standardized prevalence ratios for cancers: 0.22-0.38 among women, 0.15-0.24 among men; standardized prevalence ratios for ADNs: 0.49-0.62 among women, 0.50-0.56 among men). The results of this cross-sectional study suggest that ADN prevalence at screening colonoscopies conducted 10 or more years after a negative screening colonoscopy is low. Extension of the currently recommended 10-year screening intervals may be warranted, especially for female and younger participants without gastrointestinal symptoms.

Abstract IA007: Time to extend screening colonoscopy intervals? If so, by how much and for whom? Findings at 120,000 repeat screening colonoscopies conducted 10 or more years after a negative screening colonoscopy

Abstract Background: Screening colonoscopy effectively reduces colorectal cancer (CRC) incidence and mortality by enabling detection and removal of precancerous lesions. However, evidence for the optimal interval for colonoscopic screening is limited, making this a subject of debate. A systematic review and meta-analysis of 28 studies published in 2019 found that detection of advanced neoplasms (ADN) within 10 years after a negative index colonoscopy is rare.1 This suggests that 10 year intervals for screening colonoscopy, as currently recommended,2 may be adequate. However, evidence for defining screening colonoscopy intervals beyond ten years has remained very sparse. We aimed to assess the prevalence of advanced colorectal neoplasms (ADN) at least ten years after a negative screening colonoscopy in a very large cohort of repeat screening colonoscopy participants in Germany. Methods: We derived sex- and age-specific ADN prevalences based on 120,298 repeat screening colonoscopies (women, 60.1%) conducted at ages 65+ at least 10 years since previous negative colonoscopy and reported to the German screening colonoscopy registry in 2013-2019. The findings were compared to all screening colonoscopies conducted at ages 65+ in the same period (1.25 million) by calculating standardized prevalence ratios (SPRs). Results: ADN prevalences were 3.6% and 5.2% among women and men 10 years after a negative screening colonoscopy and gradually increased to 4.9% and 6.6%, respectively, ≥14 years after a negative colonoscopy, compared to 7.1 and 11.6%, respectively, among all screening colonoscopies conducted during the same time period. Prevalences increased with age in all groups, but were consistently much lower in repeat colonoscopies conducted 10 or more years after a negative colonoscopy than among all colonoscopies within each subgroup defined by sex and age (SPRs for CRC: 0.22-0.38 among women and 0.15-0.24 among men, respectively; SPRs for ADN: 0.49-0.62 among women and 0.50-0.56 among men, respectively). Conclusions: ADN prevalences at colonoscopies conducted 10 years after a negative screening colonoscopy as currently recommended are low. Sex and age, potentially along with additional criteria,3 could guide potential risk-adapted extension of screening intervals beyond 10 years.

S2606 Hematochezia as a Rare Presentation of Primary Colonic Diffuse Large B-Cell Lymphoma

Introduction: Diffuse large B cell lymphoma is the most common subtype of non-Hodgkin's lymphoma with localization seen only in approximately 20% of patients. Gastrointestinal localization of extranodal disease is extremely rare. We present a case of an 82-year-old female who presented with occult lower gastrointestinal bleeding as the primary presentation leading to the diagnosis of diffuse large B cell lymphoma (DLBCL). Case Description/Methods: An 82-year-old female with a past medical history of partial colectomy with colostomy reversal secondary to diverticulitis presented to the hospital for bright red blood per rectum with the passage of blood clots. She had a negative screening colonoscopy 5 years prior to admission. Upon evaluation, the patient was found to be in hemorrhagic shock resulting from acute blood loss. Colonoscopy and EGD showed mild gastritis, colitis, and a deformed cecum due to previous postoperative changes. Despite packed red blood cell transfusions, the patient remained anemic and developed pancytopenia on hospital day 4. Abdominal CT imaging demonstrated thickened loop of bowel with small to borderline-enlarged mesenteric lymph nodes adjacent to the area of bowel wall thickening. Given her history, lymphadenopathy was considered to be reactive vs. metastatic in nature while biopsies from the colonoscopy were pending. Once hemodynamically stable, the patient was discharged with appropriate f. Final biopsy results of the ascending colon confirmed a diagnosis of diffuse large B cell lymphoma (DLBCL), negative for the t(8;14) translocation or MYC/IGH fusion per FISH analysis. Chemotherapy with cyclophosphamide, vincristine, and prednisolone (CVP) was initiated. Discussion: Although hematochezia in an elderly patient is a cause for malignant workup, it is a rare presentation of hematologic malignancies. Most commonly, extranodal DLBCL is seen to involve the gastric mucosa in the event that the gastrointestinal system is involved at all. Common sites of manifestation include the spleen, thymus, and lymphoid aggregate tissue in the neck. Studies have demonstrated that extranodal disease is correlated with older patient populations as well as a poorer performance score when compared to nodal disease. This case illustrates the need of considering a broad differential inclusive of hematologic malignancy when assessing a patient with lower gastrointestinal bleeding, particularly in elderly patients with associated transfusion-resistant anemia.

Interval cancers in a population-based screening program for colorectal cancer with gender-specific cut-off levels for fecal immunochemical test.

ObjectiveTo evaluate interval cancers (IC) in the population-based Swedish regional colorectal cancer (CRC) screening program of Stockholm-Gotland, which uses gender-specific cut-off levels for the fecal immunochemical test (FIT).MethodsAll individuals aged 60–69 in Stockholm-Gotland invited to the screening program in October 2015 to September 2017 were followed up 2 years after invitation. Cut-off level for a positive FIT was 40 µg/g in women and 80 µg/g in men. Those with a positive FIT were referred to colonoscopy. Screening-detected CRC (SD-CRC) and IC after negative FIT (FIT-IC) or negative screening colonoscopy (Colonoscopy-IC) were identified in the Swedish colorectal cancer register. The IC rate was calculated as IC/(FIT negatives + negative screening colonoscopies). The IC incidence rate (ICs among negatives per 100,000 person-years) in different sex and age groups was compared to the mean CRC incidence before regional screening implementation. Test sensitivity was defined as SD-CRC/(SD-CRC + FIT-IC).ResultsApproximately 214,400 individuals were invited, and in 3521 screening colonoscopies 257(6.3%) SD-CRCs were detected. During follow-up, 124 FIT-IC and 7 Colonoscopy-IC were diagnosed, yielding an IC rate of 12.6 and 6.0 per 10,000 negatives (p = 0.00005) and a test sensitivity of 62% and 75% (p = 0.01) in men and women respectively. The IC incidence rate compared to CRC incidence was non-significantly lower in women.ConclusionIn the population-based screening program of Stockholm-Gotland with a cut-off of 40 µg/g in women and 80 µg/g in men, the test sensitivity was higher and the IC rate was lower in women, which might imply lowering the cut-off level in men. However, the IC incidence rate relative to the CRC incidence was similar in both genders.

S3492 Colon Cancer at 30? What’s Next? A Case of Lynch Syndrome With Negative Screening Colonoscopy After Right Hemicolectomy

S3492 Colon Cancer at 30? What’s Next? A Case of Lynch Syndrome With Negative Screening Colonoscopy After Right Hemicolectomy

Detection of Postcolonoscopy Colorectal Neoplasia by Multi-target Stool DNA.

INTRODUCTION:Significant variability between colonoscopy operators contributes to postcolonoscopy colorectal cancers (CRCs). We aimed to estimate postcolonoscopy colorectal neoplasia (CRN) detection by multi-target stool DNA (mt-sDNA), which has not previously been studied for this purpose.METHODS:In a retrospective cohort of patients with +mt-sDNA and completed follow-up colonoscopy, positive predictive value (PPV) for endpoints of any CRN, advanced adenoma, right-sided neoplasia, sessile serrated polyps (SSP), and CRC were stratified by the time since previous colonoscopy (0–9, 10, and ≥11 years). mt-sDNA PPV at ≤9 years from previous average-risk screening colonoscopy was used to estimate CRN missed at previous screening colonoscopy.RESULTS:Among the 850 studied patients with +mt-sDNA after a previous negative screening colonoscopy, any CRN was found in 535 (PPV 63%). Among 107 average-risk patients having +mt-sDNA ≤9 years after last negative colonoscopy, any CRN was found in 67 (PPV 63%), advanced neoplasia in 16 (PPV 15%), right-sided CRN in 48 (PPV 46%), and SSP in 20 (PPV 19%). These rates were similar to those in 47 additional average risk persons with previous incomplete colonoscopy and in an additional 68 persons at increased CRC risk. One CRC (stage I) was found in an average risk patient who was mt-sDNA positive 6 years after negative screening colonoscopy.DISCUSSION:The high PPV of mt-sDNA 0–9 years after a negative screening colonoscopy suggests that lesions were likely missed on previous examination or may have arisen de novo. mt-sDNA as an interval test after negative screening colonoscopy warrants further study.

S0340 A Single Academic Center's Experience With Direct Access Colonoscopy

INTRODUCTION: Direct Access Colonoscopy (DAC), which does not require pre-colonoscopy consultation, may improve access for patients (pts) needing screening and surveillance. Eligibility criteria for DAC vary widely. We developed a DAC program using data (age, BMI, medical/colonoscopy/social history, medications) from the EMR, referring doctors, and pts to assess appropriateness, inadequate preparation (prep) risk, and need for an advanced practice nurse and/or navigator. The aim of this study was to evaluate the efficacy, efficiency, and quality of our DAC program. METHODS: We conducted a retrospective, single center study of consecutive pts referred for DAC over 13 months. Pts were age 45–75 with an indication of screening or surveillance. Excluded were pts with symptoms or pre-colonoscopy consultation. The primary endpoint was Complete Colonoscopy (CC): To cecum/ileum/anastomosis, adequate prep (BBPS ≥ 2 all segments), ≤90 days from contact with the GI office. Pts not meeting CC criteria were classified as Incomplete Colonoscopy (IC). Secondary endpoints: Time to CC, adenoma detection rate (ADR), and 10-year recall rate after negative screening colonoscopy. Statistics: Descriptive analyses for the DAC cohort, t-test and chi-square for CC and IC group comparisons. RESULTS: 1,668 pts met inclusion criteria. Mean age was 58, 57% were female, 65% were non-White/Other, and 86% neither Hispanic nor Latino. The indication was screening in 90% and surveillance in 10%. Following contact with the GI office for DAC, 1,042 pts (62%) met the endpoint of CC with an average interval of 35.74 days. The CC group had a mean BBPS of 7.94 with 91% using a PEG-ELS prep, an ADR of 38%, and a 10-year recall rate of 82% after a negative exam. Reasons for IC were pt cancellation (35%), no show (28%), inadequate prep (9%), scheduled > 90 days (8%), other cancelation (7%), insurance/financial (4%), medical clearance (4%), and other (5%). Table 1 presents comparisons between the CC and IC groups. Blacks were less likely than non-Blacks (57% vs. 68%; P < 0.001), and non-Whites less likely than Whites (59% vs. 69%; P < 0.001), to have a CC. A surveillance indication was more common in the CC group (12% vs. 6%; P < 0.001). CONCLUSION: About 2/3 of pts referred for DAC had a CC within 90 days, and both ADR and BBPS were high. Failure to attend colonoscopy accounted for most ICs, with few excluded for inadequate prep. Blacks were less likely, and Whites more likely, to have a CC. A surveillance indication was associated with a CC.Table 1.: Patient characteristics.

One negative colonoscopy associated with a significant reduction in colorectal cancer risk.

An observational study published in the Annals of Internal Medicine1 found significant reductions in both colorectal cancer (CRC) incidence and mortality associated with a single negative high-quality screening colonoscopy. The findings indicate an 84% reduction in incidence and a 90% reduction in mortality for up to 17.4 years. As a result, the study authors suggest that the currently recommended 10-year screening interval is safe and could safely be extended. Under current guidelines, average-risk individuals aged 50 years or older who have previously had negative colonoscopy results are recommended to undergo screening every 10 years. That recommendation is based on estimates for how long it takes for adenomas and carcinomas to develop. However, longterm data are lacking on optimum follow-up intervals. The study was conducted by researchers from the Maria Sklodowska-Curie National Research Institute for Oncology in Warsaw, Poland. They analyzed a screening registry of 165,887 people and assessed both long-term CRC risk and CRC death after a single negative low- or high-quality screening colonoscopy. Their findings show that although a single negative screening colonoscopy was associated with significantly reduced CRC incidence and mortality during the 17-year screening period, only a high-quality colonoscopy led to a profound and stable reduction. Among women, high quality was key for long-term efficacy in screening colonoscopy in the proximal colon. These findings are particularly important because previous studies have questioned the efficacy of colonoscopy in the proximal colon as well as screening sigmoidoscopy in women.

Benefit of a Single Negative Screening Colonoscopy Might Extend Beyond 10 Years

Little direct evidence supports the recommendation for repeat screening colonoscopy at 10 years after a negative study, and some evidence suggests that

Long-Term Colorectal Cancer Incidence and Mortality After a Single Negative Screening Colonoscopy.

Current guidelines recommend a 10-year interval between screening colonoscopies, but evidence is limited. To assess the long-term risk for colorectal cancer (CRC) and death from CRC after a high- and low-quality single negative screening colonoscopy. Observational study. Polish Colonoscopy Screening Program. Average-risk individuals aged 50 to 66 years who had a single negative colonoscopy (no neoplastic findings). Standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) of CRC after high- and low-quality single negative screening colonoscopy. High-quality colonoscopy included a complete examination, with adequate bowel preparation, performed by endoscopists with an adenoma detection rate of 20% or greater. Among 165887 individuals followed for up to 17.4 years, CRC incidence (0.28 [95% CI, 0.25 to 0.30]) and mortality (0.19 [CI, 0.16 to 0.21]) were 72% and 81% lower, respectively, than in the general population. High-quality examination resulted in 2-fold lower CRC incidence (SIR, 0.16 [CI, 0.13 to 0.20]) and mortality (SMR, 0.10 [CI, 0.06 to 0.14]) than low-quality examination (SIR, 0.32 [CI, 0.29 to 0.35]; SMR, 0.22 [CI, 0.18 to 0.25]). In multivariable analysis, the hazard ratios for CRC incidence after high-quality versus low-quality colonoscopy were 0.55 (CI, 0.35 to 0.86) for 0 to 5 years, 0.54 (CI, 0.38 to 0.77) for 5.1 to 10 years, and 0.46 (CI, 0.25 to 0.86) for 10 to 17.4 years. Only after high-quality colonoscopy did the SIR and SMR for 10.1 to 17.4 years of follow-up not differ compared with earlier observation periods. The general population was used as the comparison group. A single negative screening colonoscopy was associated with reduced CRC incidence and mortality for up to 17.4 years. Only high-quality colonoscopy yielded profound and stable reductions in CRC incidence and mortality throughout the entire follow-up. Polish Ministry of Health.

Issue highlights

Issue highlights

Association of colorectal carcinoma and metabolic syndrome.

Aim Colorectal carcinoma is one of the most common neoplasms, especially in Western countries and those with westernisation. On the other hand, high rate of metabolic syndrome (MetSy) has also been noticed, as well as in Western countries. It seems like these two conditions are somehow connected. In this study, we wish to explore some characteristics of colorectal carcinoma and its correlation with MetSy. Methods In this retrospective study the data were taken from medical records of 67 patients with colorectal carcinoma, and for 30 healthy controls. Input parameters of patients were compared mutually, as well as with parameters of healthy, control examinees that had negative screening colonoscopy for neoplasm. Results Average age of patients was 68 years. The most frequent localisation of neoplasm was on rectum (53.7%) and most frequent level was Dukes C (38.8%). The patients had MetSy more frequently when compared with controls (p=0.048), and also they had more MetSy components (p=0.006). The link between MetSy and localisation of neoplasm was not found, neither with its pathohystological characteristics. Conclusion Patients with MetSy should be warned about the increased risk of colorectal carcinoma, and, in this way, motivated for earlier and more frequent screening colonoscopies, as well as of a change of unhealthy lifestyle.

Outcomes at follow-up of negative colonoscopy in average risk population: systematic review and meta-analysis

ObjectiveTo review and summarise the evidence on the prevalence of colorectal adenomas and cancers at a follow-up screening colonoscopy after negative index colonoscopy, stratified by interval between examinations and by...

Quality indicators for screening colonoscopy and colonoscopist performance and the subsequent risk of interval colorectal cancer: a systematic review.

The objective of this review was to assess the association between quality indicators used to evaluate individual colonoscopist performance and subsequent interval colorectal cancers (CRCs) in patients participating in bowel cancer screening programs. Colorectal cancer is a leading cause of cancer death. Bowel cancer screening has been shown to reduce CRC mortality and morbidity, and has therefore been introduced in many countries. Endoscopy societies have developed quality assurance guidelines and guidelines on quality indicators for screening colonoscopies. These quality indicators need to be validated against a relevant outcome to assess their value. We included studies on screening colonoscopies conducted on participants in a bowel cancer screening program, regardless of comorbidity. Studies on procedures performed on patients with known CRC, hereditary nonpolyposis colorectal cancer or familial adenomatous polyposis were excluded. We also included studies evaluating the quality indicators of withdrawal time (WT), cecal intubation rate (CIR) and adenoma detection rate (ADR). The search did not reveal any studies evaluating the quality indicators polyp retrieval rate and incomplete adenoma resection/incomplete polyp resection. Only studies with interval CRC as an outcome were included (i.e. CRC diagnosed after a negative screening colonoscopy, but before the next recommended examination date). Published studies were searched in: MEDLINE, Embase, Web of Science and CINAHL. Unpublished studies were searched in: OpenGrey and Grey Literature Report. The sources were searched from 1980 to2018. Data were extracted using the JBI critical appraisal checklist for analytical cross sectional studies. A meta-analysis was conducted based on three of the colonoscopist dependent quality indicators: WT, CIR and ADR. Seven prospective and retrospective cohort studies were included out of 2373 papers identified after duplicates were removed. The included studies were on bowel cancer screening programs with colonoscopy as the primary screening tool, resulting in the inclusion of a total of 616,390 screening colonoscopies performed by 1431 colonoscopists and 2319 subsequent interval CRCs. Six studies were assessed as high-quality studies, and one study was of low quality. The meta-analysis on WT revealed a 61% lower risk of interval CRC among the patients if the mean WT per colonoscopist was >6 minutes as compared to a mean WT of <6 minutes (RR: 0.39 [95% CI: 0.23 - 0.66]). The meta-analysis on CIR revealed a 31% lower risk of interval CRC among the patients if the CIR per colonoscopist was ≥90% as compared to a CIR of <85% (RR: 0.69 [95% CI: 0.56 - 0.83]). One of two meta-analyses on the individual colonoscopist ADR suggested that this should be 15-19%, as compared to an ADR <10% (RR: 0.77 [95% CI: 0.62 - 0.96]), in order to significantly reduce the risk of interval CRC. The other meta-analysis on ADR revealed a significant association between an individual colonoscopist ADR of ≥25% and a lower risk of interval CRC as compared to an ADR of <25% (RR: 0.51 [95% CI: 0.33 - 0.80]). The meta-analyses on WT and CIR showed no heterogeneity concerning the significant results (I = 0.0%). A high variability across studies due to heterogeneity concerning an ADR of ≥20% resulted in an I = 59.9%, and an I = 63.2% for an ADR of ≥25%. To minimize the risk of interval CRC, it may be recommended that WT and CIRs are monitored in bowel cancer screening programs, with an optimal individual colonoscopist mean withdrawal time of >6 minutes and a cecal intubation rate of ≥90%. In bowel cancer screening programs using colonoscopy as their primary screening tool, it may be recommended that the individual colonoscopist ADR be 15-19% or better ≥25% to minimize the risk of interval CRC.

571 – The Predictive Effect of a High-Quality Single Negative Screening Colonoscopy Exceeds 15 Years

571 – The Predictive Effect of a High-Quality Single Negative Screening Colonoscopy Exceeds 15 Years

Long-term Follow-up of Patients Having False-Positive Multitarget Stool DNA Tests after Negative Screening Colonoscopy: The LONG-HAUL Cohort Study.

Background: Studies of colorectal cancer screening by multitarget stool DNA (MT-sDNA) show false-positive (FP) rates of 7% to 13%. It is unclear whether FP patients are at increased long-term risk of adverse outcomes.Methods: We compared subsequent clinical events among patients with apparent FP MT-sDNA with those in patients reported as true negative (TN). This was a retrospective cohort study of participants in pre-FDA approval MT-sDNA studies having nonadvanced or negative baseline colonoscopy findings from a single referral center. Per-protocol and calibrated cutoffs defined FP and TN groups. From the time of stool collection, we measured differences between FP and TN groups in time to death, subsequent cancer diagnosis, and onset of alarm symptoms.Results: Of 1,050 eligible patients, only 6 were lost to follow-up. Median age was 65.6 years [interquartile range (IQR), 56.8-72.3]; 54% were female. Median follow-up time was 4 years (IQR, 3.5-5.3). Eight aerodigestive (lung and gastrointestinal tract) cancers occurred. FP status by calibrated, but not per-protocol, cutoffs was associated with subsequent aerodigestive cancer; however, cumulative incidence did not exceed SEER expectations from the general population. By any cutoff method, FP status was not associated with mortality or alarm symptoms.Conclusions: Although FP status was associated with long-term aerodigestive cancers, new cases were not temporally related and did not exceed incidence estimates from general population.Impact: These observations do not justify aggressive follow-up evaluation for patients with FP MT-sDNA at this time. Larger studies are needed to confirm these early findings. Cancer Epidemiol Biomarkers Prev; 26(4); 614-21. ©2016 AACR.

Mo1716 Long-Term Follow-Up of Patients Having False Positive Multi-Target Stool DNA Tests After Negative Screening Colonoscopy: The LONG-HAUL Study

Mo1716 Long-Term Follow-Up of Patients Having False Positive Multi-Target Stool DNA Tests After Negative Screening Colonoscopy: The LONG-HAUL Study

Sa1437 Indexed Natural Language Processing to Identify Adenoma Detection RATES

Quality monitoring is of increasing importance in procedural fields, especially for colonoscopy. Adenoma detection rate (ADR) predicts the risk for developing colorectal cancer (CRC) following a negative screening colonoscopy, however, finding the ADR using automation is challenging because it is tied to text reports and is not easily accessible without manual review. Natural language processing (NLP) has been used to obtain ADR, although with significant customized effort, cost, and has been limited to single institutions.

Capsule commentary on Powell et al., Rates and correlates of potentially inappropriate colorectal cancer screening in the Veterans Health Administration.

An inescapable fact of all cancer screening is that (of those undergoing screening) vastly more people will be harmed than helped. The key question then becomes: What are the qualities of the harms? For colon cancer screening, the United States Preventive Services Task Force (USPSTF) has determined that on a population basis, the quantity and quality of benefits for the 3 % outweigh the harms for the 97 % of asymptomatic adults aged 50–75 years (A Grade recommendation).1On an individual basis, a colleague nearly died after suffering a pulmonary embolus during treatment of a perforation caused during a negative screening colonoscopy. This case illustrates that individual harm can be devastating. The USPSTF recommends against routine screening between ages 75 and 85 years, stating that there may be considerations supporting it in individual patients (C Grade) and against screening those 85+ years.1 The article by Powell et al.2 does not deal with informed decision-making (which should be but is not an integral component of clinical preventive service recommendations and quality metrics3). Rather, Powell et al.2 ask an equally important related question: How often do clinicians offer colon cancer screening when the net population benefit approaches zero? Among 1 million Veteran Administration Hospital patients > 50 years who had one or more colon cancer screening procedures, over a quarter of fecal occult blood test (FOBT) tests and 14 % of colonoscopies were potentially inappropriate. Appropriate colonoscopies were more likely to be conducted at facilities where primary care providers were assigned responsibility for completing the CRC clinical reminder. These estimates—one may quibble that they are too low or too high, or generalizable to other settings—should remind all clinicians of the responsibility to optimize the benefit and minimize the harms of all clinical services we recommend to asymptomatic people. Perhaps it is also time to favor individualized clinical judgment over monolithic population screening algorithms that ignore individual clinician and patient values.3 At the very least, shared decision-making with patients who are fully informed of both the risks and benefits is needed. A better method of selecting patients at higher risk of disease would also help target those most likely to benefit from screening.