YT: Hello everyone and welcome to this ecancer expert panel discussion. Today we are discussing improving early detection of colorectal cancer. It's my great pleasure to be part of this panel.

I'd like to start by introducing myself. My name is Yegor Triliskyy. I'm a colorectal surgeon working in Sussex, United Kingdom.

And I would like other panel members to introduce themselves, please.

DG: Thank you. I am Deepa Gandhi. I'm from Ireland. I'm a former nurse endoscopist and I'm also the president of ESGENA, and it's my pleasure to take part in this panel discussion.

VR: Hello everyone, I'm Dr Violaine Randrian. I'm a gastroenterologist from Poitiers in France, and I'm mainly a digestive oncologist and excited to have this expert discussion.

GA: Hello everyone, my name is Giulio Antonelli, I am a consultant interventional endoscopist and assistant professor of gastroenterology at Humanitas University in Milano.

YT: It's a great pleasure to have a panel from different regions of Europe. And I'd like to start the discussion by finding what are your thoughts about what are the current challenges in our own countries as well as pan-European to identify colorectal cancer at an early stage.

Deepa, what are your thoughts on the current state of the problem?

DG: The biggest problem in Ireland is the demand versus capacity issue. So with screening we find we have a lot of demand. We don't have enough endoscopists or we don't have the capacity to maintain the screening services.

Also the age group we have started is we are still working on it. So our threshold for the FIT test is still at 45. So this is where we find screening is a challenge.

YT: I see. And Violaine can you share your French experience?

VR: Yeah, so in France the first issue is the participation of the target population to the screening. So we are screening people from 50 to 74 years old.

The FIT threshold is around 30 microgramme per gramme of faeces. And actually only 32 to 34% of the target population is taking part into the actual screening. Although they are invited by their GP and nowadays by their pharmacist, nurse and physiotherapist, I mean anyone who could reach out to them. And then the second step is to have them undergo the colonoscopy within a correct delay after a positive FIT test. So we have a two step wise challenge in our system.

YT: Thank you. And could you give us a brief of what are the current challenges in Italy with regards to early detection?

GA: Of course. No, I feel we are very similar to the French experience because we also have a very low threshold for FIT.

And we have managed in the years to reach 98.5% was the last number of the of the eligible population, which in Italy is from 50 to 74 years old. But the problem is exactly acceptance of the test because only in mean, let's say 35%. And we have also another problem in Italy, which is a big gradient, North-South gradient.

So we have the North that has more than double the acceptance of colonoscopy and of FIT than the South. So we really need to also have regional intensive work to actually put, let's say have an equilibrium in this because up to now we don't have this. And then also the acceptance of colonoscopy is even lower.

So there are some people that actually take the FIT test, are positive, but then do not accept colonoscopy. I think also these are even more high-risk patients that we really have to concentrate in not losing.

And then we have the issue of surveillance. The feeling is that we are over surveilling patients and we now have some evidence that this is probably the case. So we should probably free some space, some colonoscopy space, because of course, we also have this issue and by surveilling less and having the first colonoscopy for more people.

YT: With regards to the UK, I would say that the threshold of a qFIT value for asymptomatic patients for screening purposes is probably the highest.

And I think the decision on choosing the threshold of well above 100 microgrammes per gramme was again based on the same issue as Ireland is facing; a high demand and capacity of the system. I can see that different European countries have different variability in what their minimal thresholds are like.

We had a presentation from Netherlands, for example, at one of the sessions of UEG, where the shared experience was that in a screening group of patients, even with a threshold of 47, you still have a number of patients who are not subjected because they're below threshold for screening colonoscopy.

And as a result, may end up having interval or actually unscreened cancer detected at a later stage.

This brings us to the discussion and what are your thoughts in terms of how flexible we should be when deciding on screening thresholds? Should we be guided by figures only on asymptomatic patients? How do you think we should take into account some other factors, patient related factors when deciding the tailored screening techniques and strategies? What are your thoughts about kind of individualised strategies in screening programmes for colorectal cancer?

DG: I think it's a multifactorial decision that we have to make. It depends on your demand.

It depends on your capacity, how much can be accommodated, but also depends on the age group and the patient uptake. So all these factors have to be taken into account when we decide the screening programme.

YT: Thank you.

VR: There are some studies about the profiles of the patients that might be subject more to colorectal cancer. And of course, male patients are more prone to colorectal cancer. Also, it may be a confusing factor in terms of sedentarity and cardiovascular diseases.

So we tend to tailor a little the screening, especially depending on the familial history. If you have a first degree colorectal cancer in your parents or brothers, sisters, or even children, because now we have patients with colorectal cancer who have their parents alive and at age of being in the targeted population for a colorectal cancer screening. So that's modifying a lot the landscape of the screening because these people actually don't go through the FIT test.

They go directly to the colonoscopy screening in France. And then as for the threshold, in France, FIT is really used as a general population screening. So you have many exits from that population-based screening, either because you have a familial history or because you have symptoms.

So symptomatic patients don't go through the regular screening. They undergo directly colonoscopy or at least flexible sigmoidoscopy if they are bleeding or having pelvic symptoms, for instance. So I think we are trying to tailor a lot already, but it ends up, of course, with a high volume of colonoscopies that we have to handle. So that's a bit of a challenge in our health system.

And then we had this nice presentation earlier about trying to tailor more the FIT test into the COLOFIT score, which was interesting. And they were putting some way, depending on the age of the patient, on the sex, and on some blood analysis parameters.

And it ended up that they were lowering the referral, which was super interesting because they were lowering by around 25% the referral to colonoscopy, which is super efficient in terms of medical economics. But they were also lowering a bit the detection of colorectal cancers, and they kind of missed 9% of the colorectal cancer. And among those colorectal cancer, half of them were under the age of 50.

So we have to be very careful with these scores because they tend to put a lot of weight on age. And we all know that the epidemiology of colorectal cancer is evolving really fast nowadays, and we might under-refer patients under 50, so we may be very cautious with those tests.

YT: The other question I would like to ask you, thank you very much, is what are your thoughts on the performance of qFIT versus going straight to the colonoscopy screening?

GA: No, it's a great question. So first of all, I think it's really important to stress that screening is, or undergoing any kind of screening, is already something really important.

This was underlined by a landmark study, and that is the COLON-PREV study that was presented here at UEG week, which is showing that regardless of the kind of screening that you are undergoing, you have an incredible reduction of advanced colorectal cancer. Stage four colorectal cancer is more than 30% in patients that are not screened and goes to below 10% in patients that undergo screening.

Of course, screening colonoscopy as a first line screening method has an even lower threshold of a number of advanced colorectal cancer. But of course, it comes with a lot of other problems going straight away to colonoscopy.

So I think in Europe, we have largely this tradition of FIT-based filtering of patients that undergo colonoscopy. That I think is the way to go, rather than colonoscopy, since we are already overburdened in terms of access.

I think that in an era of personalised medicine, we really need more of these scores and risk stratifications, not really to, I think, to detect which patients should go or not go for colonoscopy. Because if you have an FIT test, which is over a very low threshold, you have to go to colonoscopy at some point. But if you add some other factors, for example, age, but there is recent studies also on AI-based scoring systems that use very simple methods, apart from age, they use, for example, BMI, they use FIT quantitative, they use C-reactive protein in the blood.

And this really can stratify different risk groups so you can prioritise access to colonoscopy. This means that at some point, everyone will go through colonoscopy, but maybe there are some people that have to go in two weeks and some people that can wait three months and nothing will not impact their outcome. So I think this is a very actual and important topic.

YT: Yeah, I agree. Thank you. And moving on, I would be very interested to know opinion on the panel on actually advances in the quality of assurance in endoscopy.

And I think Deepa has done so much work in the panels of European societies working in that matter, both in your country, but actually pan-European as well. What are your thoughts on the current challenges in assuring the quality of good endoscopy as a screening tool or as a after it's screen detected that someone is at risk of having a cancer? What are the main challenges we face to assure the good quality of endoscopy is provided to every patient?

DG: So one of the important things is why we're doing the colonoscopy is to detect the adenoma rate. So the importance of adenoma detection rate (ADR) is directly directed to the quality of the colonoscopy.

So one of the important things is how the patient takes the bowel prep. If the patient doesn't take adequate bowel prep, then any kind of interventions or any amount of AI or any advances is not going to be appropriate. So we focus more on patient education on how to take the bowel prep, the importance of taking the bowel prep.

We also make sure the patients have some visual aids, how to take the prep. And we also, the most important thing is patients sometimes don't take the bowel prep because they just feel it's not nice to drink. So it's so important to tell them how to drink it.

So drink it, sip it a little bit, little at a time, and also mix it with something that's palatable for them to drink and also to ensure the amount of clear fluids that they have to drink afterwards.

So these are some of the most important challenges we find as nurses. And we find nurses can do an important job when they are doing the pre-assessment of these patients.

The amount of information we give to patients over the phone before they arrive for the colonoscopy definitely improves the quality of the procedure itself.

And then again, obviously the KPIs for colonoscopy have to be adhered to, having adequate cecal intubation rates, the adenoma detection rates, the quality of the bowel prep, everything will come into it as well.

YT: Thank you very much. So bowel preparation is definitely an extremely important topic, which basically defines the success of the procedure. As well as I think another very important topic is actually training, which based on one of the presentations, which is a report of a survey done by the friends of the UEG Young Talent Group, showed that actually we're facing a big discrepancy in the quality of training across Europe. And as a result, it directly impacts our adenoma detection rate and actually the rates of post-colonoscopy cancer incidents as well.

What are your thoughts on what can be done to recognise and improve these challenges at our own workplace and within our healthcare systems?

VR: So that's the topic we are focussing on a lot at the UEG and the Education Committee is really trying to find a good way to formulate recommendations to improve the curricula across Europe. And that is a really difficult task. The easy way to go was to suggest some volumes of exams to perform during the residency, but it has failed to show accuracy.

So the suggestion was from 200, 300. We don't really know the threshold to get performative in colonoscopies. But then behind those numbers, it's really about the mentoring.

How your tutor is helping you through a number of sessions and he's just on your side to show you the correct gestures. So that's very important. And maybe the assessment more than the numbers, again, by entrustable professional activities, EPAs, have been proposed worldwide. And we really encourage the societies to design those entrustable professional activities to propose a path for the trainee throughout his learning curve in terms of colonoscopy.

And then adenoma detection rate, of course, but also quality of the resection. And an important thing, and my colleague, I think, will continue on that topic, is also about referring the patients to a high-volume centre when you identify some polyps that are not so easy to resect.

So the documentation and the description and the photographies or videos to describe what you see, I think, are critical also.

GA: Yeah, no, I completely agree. Thank you for saying all this, because as a European Society of Gastrointestinal Endoscopy, we recently published a position statement exactly on this point and of how to treat and how to understand and assess training and competence for basic endoscopy, because basic endoscopy is what we do every day.

And what you said about referral is extremely important, because it underlines that endoscopy is not just about moving correctly your hands, but it's also about knowing all the cognitive aspects, which are huge, because it's the cognitive aspects before the procedure, during the procedure, and after the procedures are all actually actively impacting the outcome of the patient. So we must know if the patient is doing the procedure correctly. We must know what to do during the procedure. And it's especially important what you said about referrals, about complex lesions, about how to refer these lesions. This is extremely important.

And I completely agree on the fact that, and we found some evidence on this during the writing of this position statement, that exactly the number of procedures is absolutely not enough to assess competence, because every one of us is different, and some people will have a certain competence after 50 procedures and others after 200 procedures.

And it's not that that defines the good endoscopist, but the good endoscopist, as we were saying, is defined by KPI, so ADR and cecal intubation, how well he or she assesses the bowel prep. So all these measurable performance indicators should be included in the training, and this is something that, for example, the UK colleagues have explored much more.

There are a lot of tools now to assess, for example, competence in polypectomy through nearly objective numbers, because, of course, every number has also a subjective component of the mentor, of the assessment. But this is really critical in effective training programme.

YT: Thank you very much. The other discussion I would be very interested to start is that at UEG this year, there are many studies exploring and presenting the role of adjuncts in screening for polyps and flat lesions, serrated lesions, analysing how these adjuncts can improve the detection, specifically the flat lesions, the flat lesions on the right side.

There are studies presented on the water immersion, using caps, using chromoendoscopy, using AI, and all various different tools aimed to improve our identification.

What are your thoughts about the studies being presented, how we should critically appraise the results? What are your thoughts how the detection rate actually translates into any meaningful results in the long term and the outcomes which are important for patients and for us as clinicians?

DG: I would say there's no one size fits all. So I know there's a lot of advances. You have AI, you also have mentioned about the underwater immersion with the colonoscopies and the resection.

But everybody has to be competent in what they are doing. And we also have to have a team of people who would be competent in doing. So the training is also important.

As you mentioned clearly, it's not just about the number of procedures you do, but it's also based on how effective you are, how competent you are, and confident you are in following those techniques. So, yes, there's multiple modalities, we should be able to embrace them, but we need to embrace which is appropriate for us as well.

YT: Thank you.

VR: Yes, I'm always a bit confused by those studies because I think in the results we saw, there's always an increase also in the duration of the examination. And I think that's the main point.

You need to spend enough time examining the colon wall to identify anything and to describe properly what you are seeing. So that would be my main point. The goal is the examination and diagnosis and not just reaching the cecum and going back.

YT: Thank you.

GA: I feel that we are in a very lucky position because if we look back 5, 10, 15 years ago, we didn't really have so many means to increase our ADR. And it's interesting because we have, I think, very serious network meta-analysis now, that recent ones in big journals that show us that all of these methods have an impact on the adenoma detection rate.

So there is also a hierarchy in this. So we know that artificial intelligence is one of the best ways of improving ADR. But it doesn't mean that if you don't have artificial intelligence, then you are doomed to not have a high ADR because other methods, even much cheaper and simpler methods, are not equally but anyway very effective in increasing ADR.

So I think the secret is, first of all, the technique, so the training. So knowing how to do the best examination and the zero-cost modalities. For example, two passes in the right colon or retroflection in the cecum.

It's not dangerous and it's easy and zero more cost to actually increase your ADR. Then whatever tool you have, use, because every tool has actually an impact. And if you have more than one tool that addresses different parts of the recognition error, for example, you have a tool that increases mucosal exposure, like caps or whatever, and tools that increase recognition error, so like, for example, artificial intelligence, you can combine them and the combination is even more effective than the single weight of these interventions themselves.

So the key is to use well what you have in your own environment.

YT: Giulio, Violaine, Deepa, thank you very much for a very interesting and engaging discussion.