Post-colonoscopy Colorectal Cancer Research Articles

S249 What’s in a Name? The Global Burden of Postcolonoscopy Colorectal Cancer Using WEO Terminology

S249 What’s in a Name? The Global Burden of Postcolonoscopy Colorectal Cancer Using WEO Terminology

S291 Sessile Serrated Polyp Detection Rate of 2% or Greater Is Associated With a Lower Risk for Post-Colonoscopy Colorectal Cancer

S291 Sessile Serrated Polyp Detection Rate of 2% or Greater Is Associated With a Lower Risk for Post-Colonoscopy Colorectal Cancer

Systematic review with meta-analysis: the prevalence of post-colonoscopy colorectal cancers using the World Endoscopy Organization nomenclature.

Post-colonoscopy colorectal cancers (PCCRCs) have been proposed as a performance metric for colonoscopy quality assurance programs. Previously, there was no standardised terminology or reporting methods. In 2018, the World Endoscopy Organization (WEO) advised standardised definitions and prevalence calculation methodology. To assess PCCRC burden using WEO standardised methods, to explore causes of heterogeneity, and to review changes in prevalence over time METHODS: We updated a prior systematic review by searching Ovid MEDLINE and EMBASE databases from 1 January 2013 to 31 January 2021 to identify population-based studies (or multicentre studies representative of the local population) reporting PCCRC prevalence (PROSPERO [CRD42020183796]). Two authors independently determined study eligibility, assessed quality, and extracted data. We estimated the PCCRC 3-year prevalence using WEO-recommended methodologies and investigated between-study sources of heterogeneity. We examined changes in prevalence over time. Fifteen studies reporting on 25872 PCCRC cases met eligibility criteria. Pooled PCCRC 3 year prevalence was 8.2% (95% CI=6.9%-9.4%, I2 =98.2%) across four European studies using WEO precise methodology. Proximal PCCRC prevalence was greater than distal (9.7% [95% CI=7.0%-12.4%] vs 5.4% [95% CI=2.9%-7.8%], I2 =99.2%). Seven studies reporting PCCRC rates over time showed no consistent trend: four showed a decrease, one an increase and two were unchanged. Between-study heterogeneity was high. Pooled 3-year PCCRC prevalence was 8.2% (95% CI=6.9%-9.4%). Despite WEO standardised methodology to define and calculate PCCRC rates, there was significant heterogeneity among studies. Comparing rates between populations remains challenging and additional studies are needed to better understand the global PCCRC burden to inform quality assurance programs.

Author commentary on Frederikke Schønfeldt Troelsen et al.

Frederikke Schønfeldt Troelsen et al. Risk of a post-colonoscopy colorectal cancer diagnosis in patients with inflammatory bowel disease: a population-based cohort study

Clinical and endoscopic characteristics of post-colonoscopy colorectal cancers detected within 10 years after a previous negative examination.

Abstract Background and study aims We sometimes encounter colorectal cancer (CRC) that is discovered during the time interval between initial colonoscopy and the recommended follow-up examination. Although several studies reported such cases of CRC, most were based on registry data, which implied that the endoscopic quality was not consistent or guaranteed. We aimed to clarify these clinical and endoscopic characteristics at our high-volume center where a retrospective survey could be precisely performed. Patients and methods We retrospectively analyzed patients with CRC who underwent endoscopic resection or surgery from April 2002 to December 2010, categorizing them into two groups: a “study group” of patients with a negative colonoscopy during the previous 10 years, and a “control group” of patients without a previous colonoscopy or with a previous colonoscopy more than 10 years prior. Results A total of 2042 patients had CRC, among which 55 patients were classified into the study group and the remaining 1989 into the control group. The CRC cases in the study group showed a significant association with smaller (< 30 mm) tumor size (odds ratio [OR] 2.3; 95 % confidence interval [CI] 1.3–4.0) and proximal tumor site (OR 1.7; 95 %CI 0.9–2.9). In addition, right-sided and depressed-type T1 CRCs were significantly more common in the study group. Conclusions Tumor size and location were associated with CRCs detected within 10 years after the negative examination. In addition, depressed-type T1 CRCs were more common. Therefore, we should pay more attention to small, right-sided, or depressed-type tumors in daily colonoscopy.

Risk of post colonoscopy colorectal cancer following screening colonoscopy with low-risk or no adenomas: A population-based study.

In the Danish faecal occult blood test based bowel cancer screening programme, the first round was rolled out over 4years. After roll-out, the planned faecal test recall procedure for individuals with either no or low risk adenomas at colonoscopy is 8 and 2years, respectively. Here, we aimed to investigate the post colonoscopy colorectal cancer incidence in these two groups. All Danish screening individuals from 2014 to 2015 with a positive faecal test and either no or low risk adenomas at colonoscopy were included and followed for 3years post screening for the event of colorectal cancer through national registries. Out of 533,023 submitted faecal tests and 36,673 positive tests, 17,627 had no or low risk adenomas. We identified 60 (0.34%) individuals diagnosed with colorectal cancer within 3years, 18 (0.29%) in the low risk adenoma group, and 42 (0.37%) in the no adenomas group (p=0.44). Advancing age (HR=1.079, p<0.001) and higher faecal test value (HR=1.001, p=0.002) increased hazard of colorectal cancer occurrence, whereas male sex (HR=1.3, p=0.308) and having low risk adenomas (HR=0.729, p=0.264) did not. We found no difference in post colonoscopy colorectal cancer occurrence between individuals with either no or low risk adenomas. Instead, advancing age and increased faecal test value was associated with a higher risk of post colonoscopy colorectal cancer.

A single-centre analysis of post-colonoscopy colorectal cancer.

A prospective registration of patients with colorectal cancer and a colonoscopy within the last 10 years. We tried to classify these post-colonoscopy colorectal cancers (PCCRCs) by most reasonable explanation and into subcategories suggested by the World Endoscopy Organization (WEO) and calculated the unadjusted PCCRC rate. 47 PCCRCs were identified. The average age at diagnosis of PCCRC was 73 years. PCCRCs were more located in the right colon with a higher percentage of MSI-positive and B-RAF mutated tumours. The average period between index colonoscopy and diagnosis of PCCRC was 4.2 years. Sixty-eight % of all PCCRCs could be explained by procedural factors. The mean PCCRC-3y of our department was 2.46%. The data of our centre are in line with the data of the literature from which can be concluded that most postcolonoscopy colorectal cancers are preventable. The PCCRC-3y is an important quality measure for screening colonoscopy. Ideally all centres involved in the population screening should measure the PCCRC-3 y annually, with cooperation of the cancer registry and reimbursement data provided by the Intermutualistic Agency (IMA).

A Polyp Worth Removing: A Paradigm for Measuring Colonoscopy Quality and Performance of Novel Technologies for Polyp Detection.

Leaving no significant polyp behind while avoiding risks due to unnecessary resections is a commonsense strategy to safely and effectively prevent colorectal cancer (CRC) with colonoscopy. It also alludes to polyps worth removing and, therefore, worth finding. The majority of "worthy" precancerous polyps are adenomas, which for over 2 decades, have received the most attention in performance research and metrics. Consequently, the detection rate of adenomas is currently the only validated, outcome-based measure of colonoscopy demonstrated to correlate with reduced risk of postcolonoscopy CRC. However, a third or more of postcolonoscopy CRCs originate from sessile serrated polyps (SSPs), which are notoriously difficult to find, diagnose and completely resect. Among serrated polyps, the agreement among pathologists differentiating SSPs from non-neoplastic hyperplastic polyps is moderate at best. This lack of ground truth precludes SSPs from consideration in primary metrics of colonoscopy quality or performance of novel polyp detection technologies. By instead leveraging the distinct endoscopic and clinical features of serrated polyps, including those considered important due to proximal location and larger size, clinically significant serrated polyps represent serrated polyps worth removing, enriched with subtle precancerous SSPs. With the explosion of technologies to assist polyp detection, now is the time to broaden benchmarks to include clinically significant serrated polypss alongside adenomas, a measure that is relevant both for assessing the performance of endoscopists, and for assessing new polyp detection technologies.

Postcolonoscopy Colorectal Cancer: An Overview and Future Directions

AbstractOver the past decade, there has been a great interest in postcolonoscopy colorectal cancer (PCCRC). Its etiology is complex and multifactorial. Monitoring for PCCRC is even more complex. The strategies to decrease the incidence of PCCRC start by defining the problem, identifying the factors contributing to its development, followed by an attempt to define methods to decrease its incidence. We believe that the quality of the colonoscopy and the endoscopist's expertise are the key factors in decreasing the incidence of PCCRC.

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.

Characteristics and Survival of Patients With Inflammatory Bowel Disease and Postcolonoscopy Colorectal Cancers

Postcolonoscopy colorectal cancers (PCCRCs) account for up to 50% of colorectal cancers (CRCs) in patients with inflammatory bowel disease (IBD). We investigated characteristics of IBD patients with PCCRC and their survival. We identified IBD patients (ulcerative colitis [UC] and Crohn's disease) diagnosed with CRC from 1995 to 2015. We defined PCCRC as diagnosed between 6 and 36 months, and detected CRC (dCRC) as diagnosed within 6 months after colonoscopy. We computed prevalence ratios comparing PCCRC vs dCRC and followed up patients from the diagnosis of PCCRC/dCRC until death, emigration, or study end. Mortality was compared using Cox proportional hazards regression models adjusted for sex, age, year of CRC diagnosis, and stage. The main analyses focused on patients with UC. Among 23,738 UC patients undergoing colonoscopy, we identified 352 patients with CRC, of whom 103 (29%) had PCCRC. Compared with dCRC, PCCRC was associated with a higher prevalence of metastatic cancer (33% vs 20%; prevalence ratio, 1.64; 95% CI, 1.13-2.38), cancers showing mismatch repair deficiency (79% vs 56%; prevalence ratio, 1.40; 95% CI, 1.13-1.72), and proximally located cancers (54% vs 40%; prevalence ratio, 1.34; 95% CI, 1.06-1.69). The 1- and 5-year adjusted hazard ratios of death for PCCRC vs dCRC among UC patients were 1.29 (95% CI, 0.77-2.18) and 1.24 (95% CI, 0.86-1.79), respectively. The characteristics of UC-related PCCRC suggest tumor biology as an important factor in the progression to cancer. However, the prognosis of PCCRC appears similar to that of dCRC.

ID: 3520197 INTERIM ANALYSIS OF A MULTICENTER RANDOMIZED CONTROLLED TRIAL COMPARING THE RIGHT COLON ADENOMA AND SERRATED POLYP MISS RATES WITH COLONOSCOPY USING WATER EXCHANGE AND CARBON DIOXIDE INSUFFLATION

Missed lesions contribute to post-colonoscopy colorectal cancer (PCCRC). Single-center randomized controlled trials (RCTs) (JCG 2020 [in press]; GIE 2020;91:AB108) showed a significant reduction in right colon adenoma miss rate (rAMR) using water exchange (WE) compared to carbon dioxide (CO2) or air insufflation. Generalizability of these results awaits confirmation by a multicenter trial. We are conducting a prospective multicenter RCT to test the hypothesis that WE produces a significantly lower rAMR and right colon serrated polyp miss rate (rSPMR) than CO2 insufflation. We report a preplanned interim analysis at 50% enrollment approved by the institution review board.

ID: 3521790 DOES ARTIFICIAL INTELLIGENCE IMPROVE NEOPLASMS DETECTION RATE FOR COLONOSCOPY? - A SINGLE CENTER PILOT STUDY

Removal of neoplastic polyps during total colonoscopy reduces the mortality and morbidity of colorectal cancer. However, one-fourth of polyps are missed and some of these lesions are considered to be a cause of post-colonoscopy colorectal cancer. To reduce the perceptual error of colonoscopy, a number of computer-aided detection (CADe) systems are reported; however, its clinical efficacy is still uncertain. In this study, we conducted a prospective, non-randomized, single-center pilot study to clarify whether the CADe system improves the neoplasms detection rate.

Utilization and reproducibility of World Endoscopy Organization post-colonoscopy colorectal cancer algorithms: retrospective analysis.

Colorectal cancer (CRC) diagnosed following a cancer-negative colonoscopy is termed post-colonoscopy CRC (PCCRC). In addition to calculating PCCRC rates, the World Endoscopy Organization (WEO) recommends review of individual PCCRC cases, including categorization into interval/non-interval PCCRCs, and root cause analysis to determine the most plausible explanation. We aimed to test the usability, reproducibility, and outcomes of the WEO algorithms. All CRC cases diagnosed from January 2015 to December 2016 in a single organization were cross referenced with local endoscopy and pathology databases to identify cases of PCCRC. We assessed: 1) WEO most plausible explanation for PCCRC; and 2) WEO PCCRC interval/non-interval subtype categorization. Interobserver agreement was measured using Cohen's kappa (κ). Cases with interobserver variation underwent panel discussion to reach consensus. Among 527 patients with CRC, 48 PCCRCs were identified. A consistent most plausible explanation was found in 97 % of cases, showing almost perfect agreement (κ = 0.94). Most PCCRCs (66 %) were attributed to "possible missed lesion, prior examination adequate." Interval/non-interval categorization was consistent in 77 %, showing substantial agreement (κ = 0.67). Following panel discussion, consensus was reached in all cases. Overall, 15 % were categorized as interval and 85 % as non-interval PCCRCs (12 % type A, 31 % type B, and 42 % type C). Review of PCCRC cases using WEO recommendations was performed accurately at a local level using readily available clinical information. The high number of non-interval type B PCCRCs suggests a significant proportion of PCCRCs could be avoided by better adherence to recommended surveillance intervals.

Incidence and Long-Term Outcomes of Interval Colorectal Cancers in a Fecal Immunochemical Test Screening Program

Background: Survival of colorectal cancer detected within a screening program may largely affect the effectiveness of the screening program. Long-term outcomes of interval cancers after a fecal immunochemical test (FIT) and colonoscopy (interval type post-colonoscopy colorectal cancer; PCCRCi) within a FIT screening program are, however, rarely reported. Methods: The interval cancers occurring within a Taiwan Colorectal Cancer Screening Program in 2004-2012 comprised the study cohort and were followed until 2016. The incidence of FIT interval cancers and PCCRCi was calculated, and PCCRCi were stratified by adenoma detection rate (ADR) levels [ 42% (high)]. The survival status of those with FIT interval cancers and different PCCRCi categories were compared. Findings: In total, 2,746,478 subjects received at least one FIT screening with 1,825 (86·4%) FIT interval cancers and 288 (13·6%) PCCRCis developing during the study period. Hospitals with low ADR levels had a significantly higher incidence of PCCRCi (0·93 per 1000 person-years) than those with middle and high ADR levels (0·70 and 0·58 per 1000 person-years, respectively) (p<0·001). PCCRCi in the high ADR group presented at a more advanced stage (48·0% at stage III/IV) and had the worst survival compared with PCCRCi in other ADR groups and FIT interval cancers (p=0·004). In multivariable analysis, when compared with PCCRCi in the middle ADR group, the adjusted hazard ratio of colorectal cancer death was 1·07 (95% Confidence Interval [CI]=0·60–2·26) for PCCRCi in the low ADR group, 1·64 (95%CI=1·19–2·26) for FIT interval cancer, and 1·94 (95%CI=1·01–3·80) for PCCRCi in the high ADR group. Interpretation: Screening programs should elaborate on reducing interval cancers via different approaches, considering their magnitude and long-term outcomes, to secure its effectiveness. Different etiological and biological bases may play a key role in PCCRCi of different ADR levels. Funding Information: This study was supported by the Health Promotion Administration, Ministry of Health and Welfare, Taiwan. Declaration of Interests: None. Ethics Approval Statement: This study was approved by the Health Promotion Administration, Ministry of Health and Welfare of the Taiwanese government.

Real-time use of a computer-aided system for polyp detection during colonoscopy, an ambispective study.

This study aimed to evaluate ambispectively the effectiveness of a real-time computer-aided detection (CADe) system on the number of polyp (PPC) or adenoma per colonoscopy (APC), and polyp (PDR) or adenoma detection rate (ADR). Eight-five videos marked using the CADe system, together with the unmarked videos, were reviewed by two senior endoscopists. Polyps detected in the marked and unmarked videos were recounted in parallel. Additionally, 128 consecutive patients were enrolled for a prospective evaluation using a standard colonoscopy or the CADe monitor alternately every 2 weeks. The PC, APC, PDR and ADR were compared between the two groups. The total number of polyps reported in the unmarked and marked videos were 73 and 88, respectively (mean PPC 0.86 vs 1.04, P=0.001). The proportion of polyps detected per colonoscopy increased by 20.5%. Of the 128 prospectively enrolled patients, 186 polyps were detected. The mean PPC was higher in the CADe colonoscopy than in the standard colonoscopy (1.66 vs 1.13, P=0.039). The PDR using the CADe colonoscopy was significantly higher than that of the standard colonoscopy (78.1% vs 56.3%, P=0.008). Real-time CADe system significantly increases the PDR and PPC under the situation of a high rate of polyp detection.

A93 VOLUME OF EMR EXPOSURE IN TRAINING IS CORRELATED WITH POLYPECTOMY COGNITIVE COMPETENCE AMONGST RECENT GASTROENTEROLOGY GRADUATES

Abstract Background Competence in performing polypectomy is increasingly appreciated as a colonoscopy quality metric, as incomplete resection can lead to post-colonoscopy colorectal cancer, particularly for polyps removed using piecemeal endoscopic mucosal resection (EMR). The relationship between training experiences and cognitive competence in polypectomy has not been previously described. Aims We aimed to examine associations between training and assessment experiences, self-reported comfort, and cognitive competence in polypectomy amongst recent graduates of Canadian gastroenterology training programs. Methods An online survey was distributed to recent GI graduates (≤5 years in independent practice). The survey comprised 4 sections: (1) demographics; (2) training and assessment experiences in colonoscopy, polypectomy, and EMR; (3) self-reported comfort in performing aspects of polypectomy outlined in the Direct Observation of Polypectomy Skills Assessment Tool; and (4) performance on a 22-item multiple choice quiz intended to assess cognitive competence in polypectomy (items and correct responses to which were determined a priori based on agreement of two experts). Data was analyzed using descriptive statistics and associations between predictors (demographics, training/assessment experiences, self-reported comfort) and outcomes (quiz score) were assessed using multiple linear regression. Results There were 28 survey respondents, comprising 13 (46%) who trained in advanced endoscopy, 5 (18%) in hepatology, 2 (7%) in motility, 1 (4%) in IBD, 1 (4%) in nutrition, and 6 (21%) with no advanced training. This cohort had a mean (SD) duration in independent practice of 29.0 (18.4) months. Their mean (SD) annual volume of colonoscopy, polypectomy, and EMR in independent practice was 530 (221), 182 (76), 28 (16), respectively and they had completed 525 (203) colonoscopies, 146 (92) polypectomies, and 23 (20) EMRs in their prior training. Their mean (SD) quiz score was 71.9% (13.2%). ANOVA revealed significant score differences based on fellowship history, with those trained in advanced endoscopy achieving the highest scores (81.1%, P=0.01). Multiple linear regression revealed that the number of EMRs completed during training was significantly correlated with quiz performance (B=0.60, P=0.03). Conclusions EMR experience during training appears to be associated with cognitive competence in polypectomy in independent practice. These results suggest increasing exposure to EMR in training may improve polypectomy quality amongst practicing endoscopists. Funding Agencies CAG

Risk of a post-colonoscopy colorectal cancer diagnosis in patients with inflammatory bowel disease: a population-based cohort study.

BACKGROUND : Post-colonoscopy colorectal cancers (PCCRCs) may account for up to 50 % of all colorectal cancers (CRCs) diagnosed in patients with inflammatory bowel disease (IBD). This may reflect a high colonoscopy frequency; however, evidence remains limited. METHODS : We conducted a cohort study of IBD and non-IBD patients undergoing colonoscopy. We calculated cumulative incidence proportions (CIPs) of PCCRC at 7-36 months after first-time and subsequent colonoscopies. We also computed crude and adjusted hazard ratios (HRs) of PCCRC, comparing IBD with non-IBD patients undergoing first-time and subsequent colonoscopies. Separate analyses were conducted for consecutive colonoscopies. We calculated 3-year rates of PCCRC to estimate the proportion of IBD and non-IBD CRC patients experiencing PCCRC. RESULTS : We observed 138 and 1909 PCCRCs among 34 688 IBD and 358 217 non-IBD patients who underwent colonoscopy. The CIP of PCCRC after first-time colonoscopy was 0.21 % (95 % confidence interval [CI] 0.17 %-0.27 %) for IBD patients and 0.37 % (95 %CI 0.35 %-0.39 %) for non-IBD patients. The adjusted HR of PCCRC after a first-time colonoscopy was 0.96 (95 %CI 0.75-1.22) and the adjusted HRs after subsequent colonoscopies had point estimates around 1.0. The 3-year PCCRC rate was 24.3 % (95 %CI 20.4 %-28.7 %) for IBD and 7.5 % (95 %CI 7.2 %-7.8 %) for non-IBD patients. CONCLUSIONS : Although PCCRCs accounted for a substantial proportion of all IBD-related CRCs, IBD patients had a low CIP of PCCRC. The elevated 3-year PCCRC rates may, among other factors, stem from the increased colonoscopy frequency in IBD patients.

Prevalence and characteristics of post-colonoscopy colorectal cancers in a New Zealand regional centre: a 10-year analysis.

Post-colonoscopy colorectal cancers (PCCRC) are cancers that appear following a colonoscopy in which no cancer is diagnosed. The occurrence of PCCRC is thought to be multifactorial, reflecting both endoscopy quality and potential differences in tumour biology between detected colorectal cancers and PCCRC. To identify the prevalence and characteristics of PCCRC in a New Zealand regional centre over a 10-year period. All cases of colorectal cancer (n = 1055) in the Bay of Plenty region between 1 February 2009 and 1 February 2019 were cross-referenced with endoscopy coding records to identify patients who had undergone colonoscopy within the preceding 6-60 months in which cancer was not identified. A total of 46 patients were identified to have PCCRC, giving a prevalence of 4.4%. The majority of these patients were older (80% aged 65 years or over) and female (67%). The mean interval between index colonoscopy and diagnosis of PCCRC was 3.03 years. Most (80%) patients had existent pathology (diverticular disease or colonic polyps) at index colonoscopy, and a significant proportion (43%) developed cancer in the same colonic segment. PCCRC were evenly distributed between the left (50%) and right (50%) colon. The majority of patients (63%) had early-stage cancer. The prevalence of PCCRC in a New Zealand cohort is consistent with other international reports. Most patients with PCCRC are older, female and have early-stage disease. Of interest, a high proportion of patients developed cancer within a colonic segment with existent pathology, suggesting either missed lesions or incomplete polyp resection.

Colon Irrigation Bowel Preparation Supports Multiple Clinical Benefits in Over 8,000 Patients

This retrospective clinical study evaluates an FDA-cleared high-volume colon irrigation bowel prep (BP) for colonoscopy, performed under standard operating procedures with Austin Gastroenterology (AG, Austin, TX). Patient related outcomes in 8,364 procedures, prescribed by 33 physicians in 4.5 years, demonstrated no serious adverse events and excellent satisfaction rates. The high level of adequacy using this BP far exceeds national benchmarking thresholds for adequate colon preparations. Adequacy rates remain high even when considering poor BP risk factors and patient noncompliance with ancillary pre-preparation regimens. Our analysis demonstrates that this colon irrigation BP has excellent Boston bowel preparation scores (BBPS), associated with high-level adenoma detection rates (ADR) and sessile serrated polyp (SSP) detection rates. ADR and SSP are inversely related to the patient’s post-colonoscopy interval colorectal cancer (CRC) risk, and are similarly related to an inadequate BP. Both modeling data and performance characteristics strongly suggest that this colon irrigation BP is highly safe, effective, and will reduce the costs and risks related to inadequate BP. This, accordingly, leads to significantly improved quality outcomes, savings to the healthcare systems, and a reduction of the patient’s burden.