Clinical question list

Guideline contents > Clinical question list

Author(s):

• Cancer Council Australia Surveillance Colonoscopy Guidelines Working Party — Author

Cite this page

Cancer Council Australia Surveillance Colonoscopy Guidelines Working Party. Guidelines:Colorectal cancer/Colonoscopy surveillance/Clinical question list . In: Clinical practice guidelines for surveillance colonoscopy. Sydney: Cancer Council Australia. [Version URL: https://wiki.cancer.org.au/australiawiki/index.php?oldid=200697, cited 2023 Dec 11]. Available from: https://wiki.cancer.org.au/australia/Guidelines:Colorectal_cancer/Colonoscopy_surveillance.

Last modified:
25 March 2019 22:39:21

This page lists the questions answered by systematic review and modelling. For full details about the reviews, including the inclusion and exclusion criteria, please see the Technical report.

Advances in colonoscopy, CT colonography and other methods (section lead: Gregor Brown)

Background chapter based on general literature summary. The 2011 content was reviewed and updated where required. Practice points were included as guidance.

Colonoscopic surveillance after polypectomy (section lead: Karen Barclay)

Clinical Question SAD1: What should be the surveillance colonoscopy for patients at low risk (1-2 small <10mm tubular adenomas)?

Population	Intervention	Comparator	Outcomes	Study Type	Study Design
Patients diagnosed with 1 or 2 tubular adenomas <10mm in size which have been removed	Surveillance colonoscopy follow up schedule – 5 to 10 years colonoscopy	Alternative colonoscopy frequency schedule(s) – <5 years; or No schedule; or No comparator	Incidence of colorectal cancer Incidence of adenoma Incidence of advanced adenoma Risk of colorectal cancer Risk of adenoma Risk of advanced adenoma Complications	Intervention, aetiology	Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies

Population	Risk factor	Outcomes	Study Type	Study Design
Low risk population: Patients diagnosed with 1 or 2 tubular adenomas <10mm in size which have been removed	Surveillance time	Incidence of colorectal cancer Incidence of adenoma Incidence of advanced adenoma Risk of colorectal cancer Risk of adenoma Risk of advanced adenoma	Prognostic	Systematic reviews of Level II evidence, cohort studies

Clinical Question SAD2:

What should be the surveillance colonoscopy for patients at high risk (size ≥10mm, HGD, villosity and/or 3-4 adenomas)?

Population	Intervention	Comparator	Outcomes	Study Type	Study Design
Patients who have had a polypectomy to remove: three or more adenomatous polyps; or at least one adenoma is ≥10mm in size; or the adenomas exhibit villous or tubulovillous histology or high-grade dysplasia	Surveillance colonoscopy follow up schedule – 3 yearly colonoscopy (or any schedule given no comparator)	Alternative colonoscopy frequency schedule(s) - 5 years or 5–10 years; or No comparator	Incidence of colorectal cancer Incidence of adenoma Incidence of advanced adenoma Risk of colorectal cancer Risk of adenoma Risk of advanced adenoma Complications	Intervention, aetiology	Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies

Population	Risk factor	Outcomes	Study Type	Study Design
High risk population: Patients who have had a polypectomy to remove: three or more adenomatous polyps; or at least one adenoma is ≥10mm in size; or the adenomas exhibit villous or tubulovillous histology or high-grade dysplasia	High risk population (compared to low risk population*) Surveillance time * Patients with 1 or 2 tubular adenomas <10mm in size	Incidence of colorectal cancer Incidence of adenoma Incidence of advanced adenoma Risk of colorectal cancer Risk of adenoma Risk of advanced adenoma	Prognostic	Systematic reviews of Level II evidence, cohort studies

Clinical Question SAD3:

What is the appropriate colonoscopic surveillance after the removal of large sessile or laterally spreading adenomas?

Population	Intervention	Comparator	Outcomes	Study Type	Study Design
Patients diagnosed with adenomas ≥20mm including: large sessile adenomas; or laterally spreading adenomas which were removed by: en bloc resection Procedure performed by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)	Surveillance colonoscopy follow up schedule with colonoscopy	Alternative colonoscopy frequency schedule(s) or No comparator	*Residual/Recurrent adenoma Cancer incidence	Intervention, aetiology	Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies
Patients diagnosed with adenomas ≥20mm including: large sessile adenomas; or laterally spreading adenomas which were revmoed by piecemeal Procedure performed by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)	Surveillance colonoscopy follow up schedule with colonoscopy – <6 months	Alternative colonoscopy frequency schedule(s) or No comparator

Population	Risk factor	Outcomes	Study Type	Study Design
Patients diagnosed with adenomas ≥20mm including large sessile adenomas or laterally spreading adenomas	en bloc resection piecemeal resection endoscopic mucosal resection (EMR) endoscopic submucosal resection (ESD) surveillance time	Residual/Recurrent adenoma Cancer incidence	Prognostic	Systematic reviews of Level II evidence, cohort studies

Clinical Question SAD4:

What is the appropriate colonoscopic surveillance after the identification of sessile serrated adenomas and traditional serrated adenomas?

Population	Intervention	Comparator	Outcomes	Study Type	Study Design
Patients diagnosed with traditional serrated adenomas/polyps or; sessile serrated adenomas/polyps or sessile serrated polyps proximal to the splenic flexure +/- dysplasia +/- ≥ 10mm which have been removed	Surveillance colonoscopy follow up schedule with colonoscopy – 3 years (or any schedule given no comparator)	Alternative colonoscopy frequency schedule(s) – <3, 5 or 5-10 years; or No comparator	Incidence and location of colorectal cancer Incidence of adenoma Incidence of advanced adenoma Incidence of SSA/TSA Incidence of advanced SSA/TSA Risk of colorectal cancer Risk of adenoma Risk of advanced adenoma Risk of TSA/SSA Risk of advanced TSA/SSA	Intervention, aetiology	Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies

Population	Risk factor	Outcomes	Study Type	Study Design
Patients diagnosed with sessile serrated adenomas/polyps or traditional serrated adenomas/polyps which have been removed and are undergoing surveillance colonoscopy	Patients with traditional serrated adenomas/polyps or; sessile serrated adenomas/polyps or sessile serrated polyps proximal to the splenic flexure +/- dysplasia +/- ≥ 10mm	Incidence and location of colorectal cancer Incidence of adenoma Incidence of advanced adenoma Incidence of SSA/TSA Incidence of advanced SSA/TSA Risk of colorectal cancer Risk of adenoma Risk of advanced adenoma Risk of TSA/SSA Risk of advanced TSA/SSA	Prognostic	Systematic reviews of Level II evidence, cohort studies

Clinical Question SAD5:

What should be the surveillance colonoscopy for patients with adenoma multiplicity?

Population	Intervention	Comparator	Outcomes	Study Type	Study Design
Patients diagnosed with multiple (5-19): adenomas and/or low risk adenomas and/or high risk adenomas and/or serrated adenomas which have been removed	Surveillance colonoscopy follow up schedule with colonoscopy 1 year for five to nine adenomatous polyps ≤1 year for ≥10 adenomatous polyps Any schedule given no comparator	Alternative colonoscopy frequency schedule(s) No comparator	Incidence of colorectal cancer Incidence of adenoma Incidence of advanced adenoma Risk of colorectal cancer Risk of adenoma Risk of advanced adenoma Complications	Intervention, aetiology	Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies

Population	Risk factor	Outcomes	Study Type	Study Design
Patients diagnosed with adenomas that have been removed and are undergoing surveillance colonoscopy	Patients with multiple (5-19): adenomas and/or low risk adenomas and/or high risk adenomas and/or serrated adenomas	Incidence of colorectal cancer Incidence of adenoma Incidence of advanced adenoma Risk of colorectal cancer Risk of adenoma Risk of advanced adenoma	Prognostic	Systematic reviews of Level II evidence, cohort studies

Clinical Question SFH1:

Is the surveillance colonoscopy recommendation different for patients with adenomas who also have a family history of CRC?

Intervention studies

Population	Intervention	Comparator	Outcomes	Study Type + Design
Patients diagnosed with adenomas which have been removed AND Presence of a family history of colorectal cancer: 1 first degree relative (FDR) or second degree relative (SDR) and age (≥55 or ≥60) years at diagnosis; or 1 FDR age (<55 or <60) years at diagnosis or 2 FDR or 1 FDR and 1 SDR on the same side of the family, at any age at diagnosis Colonoscopy after 2002	Following a defined surveillance colonoscopy schedule	Alternative surveillance colonoscopy frequency schedule(s) or No comparator	Incidence of: colorectal cancer adenoma advanced adenoma Risk of: colorectal cancer adenoma advanced adenoma Complications	Intervention studies of level I to III-2 evidence

Prognostic studies

Population	Risk factor	Outcomes	Study Type + Design
Patients diagnosed with adenomas which have been removed and are undergoing surveillance colonoscopy	Presence of a family history* of colorectal cancer 1 first degree relative (FDR) or second degree relative (SDR) and age (≥55 or ≥60) years at diagnosis; or 1 FDR age (<55 or <60) years at diagnosis or 2 FDR or 1 FDR and 1 SDR on the same side of the family, at any age at diagnosis	Risk of: colorectal cancer adenoma advanced adenoma	Prognostic studies of level I to III-3 evidence

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The role of surveillance colonoscopy after curative resection for colorectal cancer (section leads: James Moore and Tarik Sammour)

Clinical Question COL1:

What is the role of pre or peri-operative colonoscopy in CRC patients?

Population	Intervention	Comparator	Outcomes	Study Design
Patients diagnosed with colorectal cancer and planned surgery	Colonoscopy performed peri-operatively including pre-operatively post-operatively	N/A	Diagnostic yield Adenoma detection rate Synchronous cancer rate Quality of life Adenomas with advanced pathological features	Cohort studies Case/controls

Clinical Question FUC1:

At what time points after CRC resection should surveillance colonoscopy be performed?

PICO Question FUC1:

In patients who have undergone resection for colorectal cancer what is the optimal follow-up colonoscopy frequency or schedule in relation to diagnostic yield, adenoma recurrence, adenomas with advanced pathological features, and quality of life?

Population	Intervention	Comparator	Outcomes	Study Design
Patients who have undergone resection for colorectal cancer	Surveillance colonoscopy follow up frequency/ schedule	An alternative surveillance colonoscopy follow up frequency/ schedule	Diagnostic yield (what % of cancer was diagnosed), adenoma recurrence, adenomas with advanced pathological features, quality of life	Comparative study with or without concurrent controls

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Colonoscopic surveillance and management of dysplasia in inflammatory bowel disease (IBD) (section lead: Rupert Leong)

IBD and risk of colorectal cancer

Clinical Question SUR1:

What is the appropriate time to commence surveillance in IBD patients (ulcerative colitis and Crohn’s patients, and effects of primary sclerosing cholangitis or family history of CRC)?

Population	Intervention	Comparator	Outcomes	Study Design
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease) with or without a family history of CRC, or primary sclerosing cholangitis	Time to commence surveillance following a diagnosis of IBD (Ulcerative colitis or Crohn’s disease)	An alternative time to commence surveillance following a diagnosis of IBD	Colorectal cancer prevelance Colorectal cancer mortality Dysplasia prevelance	Intervention and aetiology studies of all study designs

Population	Risk factors	Outcomes	Study Design/Type
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)	Family History of CRC Ulcerative colitis Crohn’s disease primary sclerosing cholangitis Duration of IBD Extent of bowel involvement Activity of disease (endoscopic) Activity of disease (histological) Intestinal damage	Colorectal cancer incidence Colorectal cancer mortality Dysplasia incidence	Prognostic studies of all design

Clinical Question SUR2:

What is the most appropriate time interval for surveillance in IBD patients based on risk?

Intervention studies

Population	Intervention	Comparator	Outcomes	Study Design
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease) with or without a family history of CRC, or primary sclerosing cholangitis	Frequency of surveillance following a diagnosis of IBD (Ulcerative colitis or Crohn’s disease)	An alternative frequency of surveillance following a diagnosis of IBD (Ulcerative colitis or Crohn’s disease)	Colorectal cancer prevalence Colorectal cancer mortality Dysplasia prevalence	Intervention studies of all study designs

Prognostic studies

Population	Risk factors	Outcomes	Study Design/Type
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)	Family History of CRC Ulcerative colitis Crohn’s disease primary sclerosing cholangitis Duration of IBD Extent of bowel involvement Activity of disease (endoscopic) Activity of disease (histological) Intestinal damage	Colorectal cancer incidence Colorectal cancer mortality Dysplasia incidence	Prognostic studies of all design

Clinical Question SUR3:

What is the recommended surveillance strategies for surveillance in IBD patients?

Population	Intervention	Comparator	Outcomes	Study Design
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)	High-definition endoscopy (HDE) Chromoendoscopy Confocal laser Endomicroscopy Narrow band imaging (NBI) Autofluorescence imaging Endoscopy with targeted biopsies	Standard white light, standard definition colonoscopy	Colorectal cancer prevalence, or Dysplasia prevalence over a specific follow-up period	Intervention studies of all study design
	Targeted biopsies	Random biopsies

Population	Index Test 1	Index Test 2	Reference standard	Outcomes
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)	Colonoscopy (white light endoscopy) High-definition endoscopy (HDE) Chromoendoscopy Confocal Laser Endomicroscopy (CLE) Narrow band imaging (NBI) Autofluorescence imaging Endoscopy with targeted biopsies Endoscopy with random biopsies	An alternative endoscopy technique listed for Index test 2 or no 2nd index test	Pathological histology	Diagnostic performance related to the detection of colorectal cancer or dysplasia, including sensitivity specificity PPV or NPV accuracy
	Targeted biopsies	Random biopsies

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Management of elevated dysplasia in IBD

Clinical Question MNG1:

What should be the protocol to manage elevated dysplasia in IBD?

PICO MNG1:

In patients who have inflammatory bowel disease (IBD) and elevated dysplasia, which management protocol achieves the best outcomes in relation to the development of colorectal cancer?

Population	Intervention	Comparator	Outcomes	Study Design
Patients who have IBD and elevated dysplasia	Management protocol for elevated dysplasia which may include: endoscopic lesions surgical interventions	An alternative management protocol	Development of colorectal cancer	Comparative studies with or without concurrent controls

Clinical Question MNG2:

What should be the protocol to manage high-grade dysplasia in IBD?

PICO MNG2:

In patients who have inflammatory bowel disease (IBD) and high-grade dysplasia, which management protocol achieves the best outcomes in relation to the development of colorectal cancer?

Population	Intervention	Comparator	Outcomes	Study Design
Patients who have IBD and high-grade dysplasia in flat musoca	Management protocol for high-grade dysplasia which may include: colectomy	An alternative management protocol	Development of colorectal cancer	Comparative studies with or without concurrent controls

Clinical Question MNG3:

What should be the protocol to manage low-grade dysplasia in IBD?

PICO MNG3:

In patients who have inflammatory bowel disease (IBD) and low-grade dysplasia, which management protocol achieves the best outcomes in relation to the prevention of progression to a higher grade of dysplasia?

Population	Intervention	Comparator	Outcomes	Study Design
Patients who have IBD and low-grade dysplasia in flat musoca	Management protocol for low-grade dysplasia which may include: colectomy chromoendoscopy surveillance	An alternative management protocol	Prevent progression to a higher grade of dysplasia	Comparative studies with or without concurrent controls

Clinical Question MNG4:

What should be the protocol to manage indefinite dysplasia in IBD?

PICO MNG4:

In patients who have inflammatory bowel disease (IBD) and indefinite dysplasia, which management protocol achieves the best outcomes in relation to the progression to colorectal cancer?

Population	Intervention	Comparator	Outcomes	Study Design
Patients with IBD and indefinite dysplasia	Management protocol for low-grade dysplasia which may include: chromoendoscopy surveillance	An alternative management protocol	Progression to colorectal cancer	Comparative studies with or without concurrent controls

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Anxiety in colonoscopy: approaches to minimise anxiety and its adverse effects (section lead: Afaf Girgis)

Background chapter based on general literature summary. The 2011 content was reviewed and updated where required. Practice points were included as guidance.

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Socio-economic factors (section lead: Anne Duggan)

Background chapter based on general literature summary. The 2011 content was reviewed and updated where required. Practice points were included as guidance.

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An adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.

The proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas, or polyps, detected.

A specialised type of endoscopy that uses specific blue and green wavelengths of light to enhance visualisation of the mucosal layer of the colon.

The surgical removal of all or part of the colon.