Neoplasia outcomes following colonoscopy for Lynch syndrome at a dedicated center vs. community centers

Abstract

Background and study aims

The European Society for Gastrointestinal Endoscopy recommends Lynch syndrome patients be followed in centers that monitor compliance and measure endoscopic performance. It is unclear if this policy impacts neoplasia outcomes. We investigated whether neoplasia outcomes were better at a dedicated center vs. community-based endoscopy centers.

Patients and methods

We reviewed findings of surveillance colonoscopy in 129 Lynch patients according to whether the previous colonoscopy was performed at a community vs. dedicated center and compared detection rates of advanced lesions (cancers plus advanced precancerous lesions) at colonoscopy.

Results

There were five cancers identified at a surveillance colonoscopy: one after a colonoscopy at the dedicated center at an interval of 137 months and four after community center colonoscopies at intervals of 12, 14, 26, and 77 months. Detection of advanced lesions (cancer plus advanced precancerous lesions) was higher after colonoscopy performed at community centers compared with the dedicated center (12.0% vs 4.1%; odds ratio [OR] 3.20; 95% confidence interval [CI] 1.30–7.90). The cancer detection rate after previous colonoscopy at community centers was 4.3%, compared with 0.4% after colonoscopy at the dedicated center (OR 12.23; 95% CI 1.4–107.2). The interval between previous and surveillance colonoscopy was longer if the previous colonoscopy was performed at a community center (934 +/- 1037 days vs. 589 +/- 445 days; P = 0.006).

Conclusions

A dedicated center with consistently high colonoscopy performance measures and navigation to augment patient adherence provided superior neoplasia outcomes in Lynch syndrome patients compared with community colonoscopy centers.

Keywords

Endoscopy Lower GI Tract - Colorectal cancer - Polyps / adenomas / ... - Quality and logistical aspects - Lynch Syndrome

Introduction

Lynch syndrome is the most common inherited colorectal cancer (CRC) syndrome, accounting for approximately 3% of all CRCs [1], with colonoscopy recommended every 1 to 3 years [1] [2] [3] [4] [5].

Detailed colonoscopy is recommended in Lynch syndrome because Lynch syndrome drives lesions through the polyp-cancer sequence more rapidly than in sporadic CRC [1]. According to this concept, even small adenomas may progress rapidly in Lynch syndrome, underscoring the need for detailed clearing of neoplasia during colonoscopy in Lynch syndrome [2] [6] [7] [8] [9].

The European Society for Gastrointestinal Endoscopy (ESGE) recommends “individuals with Lynch syndrome should be followed in dedicated centers that practice monitoring of compliance and endoscopic performance measures” [2]. Our center is such a dedicated center. We have a long history of systematic measurement of colonoscopy quality [10] [11] [12] [13] [14] and all endoscopists have adenoma detection rates (ADRs) above recommended thresholds [15]. We employ a dedicated nurse navigator to improve adherence to recommended surveillance for patients with inherited syndromes.

To explore whether a dedicated center for Lynch management impacts the type and frequency of neoplasia detected in Lynch syndrome, we sought evidence from results of surveillance colonoscopy depending on whether the previous colonoscopy had been performed at a dedicated center vs. community centers outside our institution. We hypothesized that when previous colonoscopies were performed at a dedicated center, the next surveillance colonoscopy would demonstrate a lower detection rate of CRCs and advanced precancerous lesions compared with when previous colonoscopies were performed at outside community centers.

Patients and methods

As part of an ongoing colonoscopy quality program, we maintain data on procedure indications and colonoscopy findings for all colonoscopies. Permission to review the de-identified database was granted by the Institutional Review Board at Indiana University on January 8, 2024.

Patients with Lynch syndrome are sometimes referred to our center from community centers, or may be self-referred or referred by affected family members. We examined the detection rate of surveillance colonoscopies according to whether the previous colonoscopy had been performed at our dedicated center or at an outside community center. All endoscopists in our center have ADRs above the recommended threshold, ADR has been measured continuously for more than 20 years and the majority of colonoscopies are performed by endoscopists with ADR above 40% [15]. We employ a nurse navigator dedicated to improving adherence to surveillance tests for inherited CRC syndrome patients.

Patients were eligible if they had genetically proven Lynch syndrome and had at least one surveillance colonoscopy at the dedicated center. Patients were excluded if they presented to the dedicated center for resection of a known lesion or had a symptomatic indication for colonoscopy. The very first colonoscopy performed for screening was considered the index colonoscopy. If patients had an initial index screening colonoscopy or ≥ 1 surveillance colonoscopy at a community center before transferring care to the dedicated center, then their first colonoscopy at the dedicated center was considered a surveillance colonoscopy. If the index colonoscopy was performed at the dedicated center, then the second and all subsequent colonoscopies were considered surveillance colonoscopies. Each surveillance colonoscopy was categorized according to whether the previous colonoscopy was performed at the dedicated center or a community center. In some cases, we had records from multiple colonoscopies performed at a community center, in which case, all colonoscopies at the community center performed after the first were considered surveillance colonoscopies.

Cancer was defined as adenocarcinoma with submucosal or deeper invasion. Conventional adenomas were considered advanced if they were ≥ 10 mm or had high-grade dysplasia, or villous features. Sessile serrated lesions (SSLs) were considered advanced if they were ≥ 10 mm or had cytological dysplasia. In this study, we defined advanced lesions as cancers, advanced adenomas, and advanced serrated lesions.

Outcomes

Detection rates were calculated at each of and up to four surveillance colonoscopies. The primary outcome was the advanced lesion detection rate, defined as number of patients with at least one cancer, advanced adenoma, or advanced SSL among all colonoscopies. Detection rates for adenomas, SSLs, and cancers were defined the same way. Lesions per colonoscopy were defined as the total number of lesions divided by the number of follow-up colonoscopies, and these were calculated for advanced lesions, adenomas and SSLs.

Statistical analysis

We report descriptive baseline features of the patient cohort and for the surveillance colonoscopies. Most patients had more than one surveillance colonoscopy, with some patients contributing to both groups (prior procedure at our center vs. prior procedure at an outside center). For analyzing detection rates (presence of at least one adenoma, SSL, advanced lesion, cancer) at follow-up based on prior provider (dedicated center vs. community center, defined based on the provider seen at the beginning of each surveillance interval) and time interval between procedures, we used generalized estimating equation logistic regression to analyze each detection rate, clustering on patient to account for within-patient correlation among multiple colonoscopies from the same patient, and reporting corresponding P values and odds ratios (ORs) with 95% confidence intervals (CIs). Similar analyses for numbers of adenomas, SSLs, and advanced lesions per colonoscopy were analyzed using mixed-model ANOVAs with a random subject effect to account for within-patient correlation. Freedom from advanced lesions (cancers plus advanced precancerous lesions) was quantified using Cox survival analysis to compare between the dedicated and community centers, with surveillance interval included as a covariate and a frailty term to account for within-patient correlation. The group (dedicated and community center) was again defined based on the provider seen at the beginning of each surveillance interval, time to advanced lesion was restarted with each surveillance interval, and patients were censored at end of the interval if no advanced lesions were observed. Statistical significance was set at P < 0.05. SPSS, Version 29 (IBM, New York, United States) was used for all analyses.

Results

Patient demographic and pathogenic variant analyses

There were 129 patients with genetically proven Lynch syndrome, with a median age of 44 years at index (first colonoscopy for which we had records) colonoscopy, and 64% were female. [Table 1] shows demographic features of the study population and the affected genes based on germline testing for the overall population and according to whether the first or index colonoscopy was performed at the dedicated center or at a community center. Of the 129 patients, 78 had their first or index colonoscopy at the dedicated center and 51 had their index colonoscopy at a community center. At the dedicated center, index colonoscopies were performed by 15 different endoscopists and surveillance colonoscopies by 26 different endoscopists.

Table 1 Baseline characteristics of 129 patients from the overall study population and according to whether their index (first) colonoscopy was performed at the dedicated center or a community center.

Variable	Overall, N = 129	Dedicated center, N = 78	Community center, N = 51
*Number (%) Q, quartile; SD, standard deviation; SSL, sessile serrated lesion.
Sex
Male	46 (35.7)*	30 (38.5)	16 (31.4)
Female	83 (64.3)	48 (61.5)	35 (68.6)
Age in years at index colonoscopy, mean (SD, min-max)	42.9 (14.4, 12–74)	42.1 (13.1, 17–74)	44.1 (16.3, 12–73)
Age in years at index colonoscopy, median (Q1-Q3)	44.0 (31.5–52.0)	44.0 (31.0–51.3)	42.0 (33.0–58.0)
Race
Asian	1 (0.8)*	-	1 (2.0)
Black	8 (6.2)	4 (5.1)	4 (7.8)
Unknown	1 (0.8)	-	1 (2.0)
White	119 (92.2)	74 (94.9)	45 (88.2)
Ethnicity
Non-Hispanic	128 (99.2)*	78 (100.0)	50 (98.0)
Unknown	1 (0.8)	-	1 (2.0)
Smoking status
No	102 (79.1)*	59 (75.6)	43 (84.3)
Yes, current	7 (5.4)	6 (7.7)	1 (2.0)
Yes, former	20 (15.5)	13 (16.7)	7 (13.7)
Known family history of
Lynch syndrome	76 (58.9)*	50 (64.1)	26 (51.0)
Colorectal cancer	95 (73.6)	61 (78.2)	34 (66.7)
Uterine cancer	55 (42.6)	32 (41.0)	23 (45.1)
Ovarian cancer	20 (15.5)	12 (15.4)	8 (15.7)
Genitourinary cancer	19 (14.7)	12 (15.4)	7 (13.7)
Gastric cancer	21 (16.3)	12 (15.4)	9 (17.6)
Small bowel cancer	6 (4.7)	5 (6.4)	1 (2.0)
Breast cancer	46 (35.7)	29 (37.2)	17 (33.3)
Other cancers not listed above	39 (30.2)	24 (30.8)	15 (29.4)
Known personal cancer history	68 (52.7)*	38 (48.7)	30 (58.8)
Colorectal cancer	33 (25.6)	17 (21.8)	16 (31.4)
Uterine cancer	16 (12.4)	7 (9.0)	9 (17.6)
Ovarian cancer	2 (1.6)	1 (1.3)	1 (2.0)
Genitourinary cancer	3 (2.3)	2 (2.6)	1 (2.0)
Gastric cancer	3 (2.3)	1 (1.3)	2 (3.9)
Small bowel cancer	5 (3.9)	4 (5.1)	1 (2.0)
Breast cancer	12 (9.3)	9 (11.5)	3 (5.9)
Pancreatic cancer	1 (0.8)	1 (1.3)	-
Other cancers not listed above	16 (12.4)	10 (12.8)	6 (11.8)
Gene mutation
MLH1	31 (24.0)*	24 (30.8)	7 (13.7)
MSH2	57 (44.2)	32 (41.0)	25 (49.0)
MSH6	21 (16.3)	14 (17.9)	7 (13.7)
PMS2	20 (15.5)	8 (10.3)	12 (23.5)
Initial colonoscopy finding
Normal	80 (62.0)*	46 (59.0)	34 (66.7)
Adenoma or SSL	23 (17.8)	18 (23.1)	5 (9.8)
Advanced precancerous lesions	12 (9.3)	10 (12.8)	2 (3.9)
Adenocarcinoma	14 (10.9)	4 (5.1)	10 (19.6)
Bowel resection
Total	35 (27.1)*	17 (21.8)	18 (35.3)
Left hemicolectomy	1/35 (2.9)	-	1/18 (5.6)
Partial	4/35 (11.4)	2/17 (11.8)	2/18 (11.1)
Right hemicolectomy	17/35 (48.6)	8/17 (47.1)	9/18 (50.0)
Sigmoidectomy	6/35 (17.1)	1/17 (5.9)	5/18 (27.8)
Subtotal colectomy	6/35 (17.1)	5/17 (29.4)	1/18 (5.6)
Unknown segment	1/35 (2.9)	1/17 (5.9)	-
Follow-up interval in days, mean (n, SD, min-max)
First surveillance colonoscopy	902 (129, 959.6, 127–6172)	711 (78, 582.4, 127–3153)	1196 (51, 1299.9, 128–6172)
Second surveillance colonoscopy	576 (99, 333.6, 77–2009)	549 (55, 295.5, 77–2009)	609 (44, 376.6, 189–1817)
Third surveillance colonoscopy	514 (77, 209.6, 77–1093)	519 (45, 193.0, 153–1078)	507 (32, 234.1, 77–1093)
Fourth surveillance colonoscopy	561 (57, 547.9, 108–4179)	618 (32, 693.3, 218–4179)	489 (25, 264.1, 108–1275)
Follow-up interval in days, median (n, Q1-Q3)
First surveillance colonoscopy	560 (129, 378–945)	491 (78, 384–863)	728 (51, 366–1571)
Second surveillance colonoscopy	465 (99, 372–700)	465 (55, 372–658)	455 (44, 372–730)
Third surveillance colonoscopy	420 (77, 371–708)	432 (45, 371–708)	408 (32, 370–732)
Fourth surveillance colonoscopy	415 (57, 366–561)	422 (32, 373–569)	379 (25, 364–562)

Details of detected cancers

There were 14 CRCs diagnosed in the cohort during index colonoscopies (data not shown) and five during surveillance colonoscopies, of which four were diagnosed when the previous colonoscopy was performed at a community center and one when the previous colonoscopy was performed at the dedicated center ([Table 2]). The single cancer diagnosed when the previous colonoscopy was performed at the dedicated center had an interval between colonoscopies of 137 months (11.4 years), whereas the four cancers identified after a colonoscopy performed at a community center were diagnosed at 12-, 14-, 26-, and 77-month intervals. The mean interval between colonoscopies when the previous colonoscopy was performed at a community center was 934 ± 1037 days and was 589 ± 445 days when the previous colonoscopy was at the dedicated center (P = 0.006).

Table 2 Features of five cancers identified during surveillance colonoscopy.

Number	Exam type	Prior exam location	Time since last colonoscopy (months)	Gene mutation	Age	Location	Stage
1	Surveillance	Community center	26	MSH2	58	Rectum	Unknown
2	Surveillance	Dedicated center	137	MLH1	62	Transverse	T2N0M0
3	Surveillance	Community center	77	MSH6	61	Descending	T3N0M0
4	Surveillance	Community center	12	MSH2	73	Cecum	T1bN0M0
5	Surveillance	Community center	14	MSH2	46	Ascending	T1N0M0

There were 270 surveillance colonoscopies following a colonoscopy performed at the dedicated center, of which 265 were performed at the dedicated center and five at community centers. There were 92 surveillance colonoscopies performed after a colonoscopy at community centers, of which 41 were performed at the dedicated center and 51 at community centers. [Table 3] shows the association between testing site of previous colonoscopy and detection rate of cancer and advanced precancerous lesions, without consideration of intervals between colonoscopies. There was a numerically higher detection rate for advanced neoplasia if the previous colonoscopy had been performed at a community center, and these differences reached statistical significance for cancer (4.3% vs. 0.4%; OR 12.23; 95% CI 1.40–107.2) and for advanced lesions (12.0% vs. 4.1%; OR 3.20; 95% CI 1.30–7.90). There were no other significant differences in detection measures between the arms ([Table 3]).

Table 3 Detection at follow-up procedure based on prior provider (no covariates).

	Prior provider		P value*	OR†
	Dedicated center	Community center
*All patients had at least 1 follow-up. For analyzing detection rates at follow-up based on prior provider, we therefore used mixed model ANOVA and GEE logistic regression for numerical and categorical variables, respectively. †Prior provider being community center compared to prior provider being dedicated center. ‡Advanced lesions: cancers plus advanced adenomas plus advanced serrated lesions.
Adenoma detection rate	23.0% (62/270)	29.3% (27/92)	0.263	1.39 (0.78–2.49)
Sessile serrated lesion detection rate	2.6% (7/270)	4.3% (4/92)	0.429	1.71 (0.45–6.43)
Advanced lesion‡ detection rate	4.1% (11/270)	12.0% (11/92)	0.012	3.20 (1.30–7.90)
Cancer detection rate	0.4% (1/270)	4.3% (4/92)	0.024	12.23 (1.40–107.21)
Adenomas per colonoscopy	0.46 (1.3)	0.68 (1.4)	0.138	1.25 (0.93–1.67)
Sessile serrated lesions per colonoscopy	0.03 (0.2)	0.08 (0.4)	0.244	1.05 (0.97–1.14)
Advanced lesions‡ per colonoscopy	0.05 (0.3)	0.15 (0.4)	0.057	1.11 (1.00–1.24)

[Fig. 1] shows survival curves from the Cox model for absence of advanced lesions (cancers plus advanced precancerous lesions) based on center type (dedicated vs. community; P = 0.43). Proportions of patients without advanced lesions at 2 years, 5 years, and 10 years were 93.3%, 91.6%, and 78.1% in the index colonoscopy at the dedicated center group and 96.1%, 86.1%, and 70.0% in the community center group, respectively.

Fig. 1 Cox model for absence of advanced lesions (cancers plus advanced precancerous lesions) based on center type (dedicated vs. community; P = 0.43).

Discussion

In this study, we measured detection rates of surveillance colonoscopy for advanced lesions based on whether the previous colonoscopy was performed at a dedicated center or at a community center. We found that a dedicated center employing performance measures for colonoscopy and measures to improve colonoscopy adherence, as recommended by ESGE, achieved better neoplasia outcomes for Lynch syndrome patients compared with community centers. Detection rates for CRC and advanced lesions (cancers plus advanced precancerous lesions) were lower in surveillance colonoscopy when the prior colonoscopy was performed at the dedicated center. These results support the ESGE recommendation: “individuals with Lynch syndrome should be followed in dedicated units that practice monitoring of compliance and endoscopic performance measures” [2].

These results support an important role for colonoscopy in Lynch syndrome. If colonoscopy did not impact neoplasia outcomes, there should not be an identifiable difference in detection of cancers and advanced lesions based on dedicated vs. community centers. This line of reasoning is analogous to the observation that ADR impacts post-colonoscopy CRC (PCCRC) incidence in general screening, surveillance, and diagnostic colonoscopy. Thus, if colonoscopy did not affect neoplasia outcomes it would not be possible to demonstrate a difference in PCCRC incidence between high vs. low ADR [16] [17] [18]. Our paper extends this reasoning to Lynch syndrome, and supports other evidence that colonoscopy reduces CRC risk in Lynch syndrome [19] [20] [21].

Due to the few incident CRCs, we could not discern whether improved outcomes at the dedicated center resulted from a difference in baseline risk or in colonoscopy quality, or shorter surveillance intervals. According to ESGE, dedicated centers should employ both high-quality colonoscopy and shortened intervals. Thus, appropriately short surveillance intervals should be viewed as part of a suite of quality factors and interventions that optimize outcomes in patients with Lynch syndrome, rather than a standalone factor.

Strengths of this study are inclusion of patients with genetically proven Lynch syndrome and detailed information on index and subsequent colonoscopy findings along with timing of surveillance intervals. Limitations include the small sample size, which precluded doing a robust, valid multivariable analysis to identify other factors that might increase cancer risk, such as weight, smoking history, and affected Lynch gene. Although some results were both clinically important and statistically significant, other results showed no difference statistically, likely due to the small sample size. These results include differences in the time-to-event analysis, adenomas per colonoscopy, and detection rates for any adenoma and SSLs ([Table 3]). Further, because the study is retrospective, unseen differences in baseline risks for neoplasia between dedicated and community center patients may contribute to some of the observed differences in incidence of advanced neoplasia between the groups.

However, given the already high genetically determined risk for CRC in this cohort, we consider that differences in other baseline features are unlikely to account for differences in detection rates. No substantial differences in demographics or mutated gene are apparent from comparison of patients who had their index colonoscopy at the dedicated center vs. a community center ([Table 1]). Further, the short intervals between colonoscopy and CRC in three cases in which the previous colonoscopy was performed at a community center (12, 14, and 26 months) suggest that differences in colonoscopy quality contributed to the main study results. No cancers at short intervals were observed after colonoscopy performed at the dedicated center. The next step in establishing appropriateness of the ESGE recommendation is conducting a large multicenter study examining detection rates for CRC and advanced precancerous lesions after previous colonoscopy at dedicated centers vs. general community endoscopy centers.

Conclusions

In conclusion, we describe evidence that a dedicated center with consistently high colonoscopy performance measures and navigation to augment patient adherence provided superior neoplasia outcomes in Lynch syndrome patients compared with community colonoscopy centers. Our data support the ESGE recommendation that “individuals with Lynch syndrome should be followed in dedicated units that practice monitoring of compliance and endoscopic performance measures” [2].

Contributorsʼ Statement

Alex Stout: Data curation, Investigation, Writing - original draft, Writing - review & editing. Connor D. McWhinney: Data curation, Investigation, Writing - original draft, Writing - review & editing. Rachel E. Lahr: Data curation, Investigation, Project administration, Supervision, Writing - review & editing. Jennifer Maratt: Writing - review & editing. John J. Guardiola: Writing - review & editing. Krishna C Vemulapalli: Data curation, Formal analysis, Methodology, Writing - review & editing. Charles J. Kahi: Methodology, Writing - review & editing. Thomas Imperiale: Formal analysis, Methodology, Writing - review & editing. Douglas K. Rex: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing - original draft, Writing - review & editing.

Conflict of Interest

JJG – Travel Support: Olympus Corporation, Boston Scientific Corporation, Ovesco Endoscopy AG KCV is a salaried employee of Cook Research Incorporated, a Cook Group company; DKR – Consultant: Boston Scientific, Olympus Corporation, Braintree Laboratories, Sebela Pharmaceuticals, Laborie, Medtronic; Research Support: Boston Scientific, Sebela Pharmaceuticals, Medtronic, Olympus Corporation, Erbe, Laborie; Ownership interest: Dova Health Intelligence. All remaining authors declare no conflict of interest.

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Publication History

Received: 12 June 2025

Accepted after revision: 05 January 2026

Accepted Manuscript online:
20 January 2026

Article published online:
10 February 2026