CADe colonoscopy in colorectal cancer screening - ESGE Postional Statement

The ESGE (European Society of Gastrointestinal Endoscopy) Position Statement on computer-assisted detection (CADe) in colonoscopy for colorectal cancer (CRC) screening and post-polyp surveillance provides a cautious but favorable recommendation for its use. Here is a comprehensive summary of the statement and its implications:

### What is CADe in Colonoscopy?

CADe, or computer-assisted detection, is an artificial intelligence (AI) tool designed to enhance the detection of polyps during colonoscopy procedures. Polyps are growths in the colon or rectum that can sometimes develop into colorectal cancer if left untreated. CADe systems analyze the video feed from the colonoscope in real-time, helping endoscopists identify polyps that might otherwise be missed, particularly small or flat polyps that are more challenging to detect.

### ESGE's Evaluation Process

The ESGE Position Statement was developed through a structured evaluation process, which included:

1. **Systematic Reviews**: A thorough review of existing evidence on CADe's effectiveness and safety.

2. **Microsimulation Modeling**: Simulations to predict the potential impact of CADe on colorectal cancer incidence and mortality.

3. **Patient Values and Preferences**: Consideration of patient perspectives regarding the use of this technology in screening and surveillance.

A panel of European experts assessed the evidence, weighing the potential benefits and harms of CADe use during colonoscopy. The final vote on December 18, 2024, showed a majority (68.4%, or 13 out of 19 members) in favor of recommending CADe, while 31.6% (6 members) voted against it, highlighting ongoing uncertainty in the field.

### ESGE's Recommendation

The ESGE issued a **weak but favorable recommendation** for the use of CADe in colonoscopy for CRC screening and post-polyp surveillance. The key points of the recommendation are as follows:

1. **Potential Benefits**:

• **Improved Polyp Detection**: CADe enhances the detection of small and flat polyps, which are often missed during traditional colonoscopy. This improvement could help prevent the progression of these polyps into colorectal cancer.
• **Reduction in CRC Incidence and Mortality**: Evidence suggests that CADe may lead to a small but meaningful reduction in the rates of colorectal cancer and related deaths.

2. **Concerns and Limitations**:

• **Limited Evidence**: The current body of research supporting CADe is still limited and carries significant uncertainty.
• **Modest Absolute Benefit**: While CADe shows promise, the overall reduction in cancer cases and deaths is considered modest.
• **Risk of Overdiagnosis**: CADe increases the detection of non-threatening polyps, which could lead to overdiagnosis, unnecessary follow-up colonoscopies, and increased patient burden.

3. **Patient Preferences**:

• The panel concluded that most well-informed patients who have already decided to undergo colonoscopy for screening or surveillance would likely prefer CADe-assisted procedures, given the potential for improved detection.

### Overall Conclusion

The ESGE cautiously supports the use of CADe during colonoscopy, recognizing its potential to improve polyp detection and reduce colorectal cancer incidence and mortality. However, the recommendation is classified as weak due to the limited strength of current evidence, the modest absolute benefits, and the potential downsides, such as overdiagnosis and increased surveillance burden.

The ESGE emphasizes the importance of balancing these benefits with patient preferences and the risks of unnecessary procedures. Further high-quality research is needed to strengthen the evidence base and address the uncertainties surrounding CADe's role in colorectal cancer screening and surveillance.