Colorectal, in full.

All patients meeting clinical criteria for, or carrying a pathogenic germline variant of, a hereditary GI cancer syndrome should have pre- and post-test genetic counseling, and at-risk first-degree relatives should be offered genetic testing. Syndrome-specific surveillance: LYNCH SYNDROME, colonoscopy at least every 2 years (annual colonoscopy should be considered in confirmed mutation carriers), beginning at age 20-25 years, or 2-5 years before the earliest CRC diagnosis in the family if that was before age 25; baseline EGD with gastric biopsy and test-and-treat for H. pylori at age 30-35, with ongoing upper-GI surveillance every 3-5 years where family history of gastric/duodenal cancer exists; annual endometrial biopsy and transvaginal ultrasound from age 30-35, with prophylactic hysterectomy/bilateral salpingo-oophorectomy offered after childbearing; surveillance BEYOND population-based recommendations for the urinary tract, pancreas, breast and prostate is NOT recommended unless supported by family history. CLASSIC FAP, annual sigmoidoscopy or colonoscopy beginning at puberty; colectomy indicated for documented/suspected cancer or significant symptoms (absolute), or for relative indications such as multiple adenomas >6 mm or a significant increase in adenoma number that make endoscopic control unfeasible; upper-GI surveillance by EGD/duodenoscopy from age 25-30, repeated every 0.5-4 years by Spigelman stage, plus annual thyroid ultrasound. AFAP, surveillance by colonoscopy (not sigmoidoscopy, as polyps are right-sided) with polypectomy every 1-2 years, beginning in the late teens to early 20s; upper-GI surveillance by EGD/duodenoscopy from age 25-30, repeated every 0.5-4 years by Spigelman stage, plus annual thyroid ultrasound (as for classic FAP). MUTYH-ASSOCIATED POLYPOSIS (biallelic MUTYH), colonoscopy every 1-2 years beginning at age 25-30; upper-GI surveillance by EGD/duodenoscopy from age 25-30, repeated every 0.5-4 years by Spigelman stage, plus annual thyroid ultrasound (as for classic FAP). SERRATED POLYPOSIS SYNDROME, colonoscopy every 1-3 years with attempted removal of all polyps >5 mm.

After polyp removal, assign the next colonoscopy surveillance interval using USMSTF 2020 based on polyp number, size, and histology (e.g., 1-2 tubular adenomas <10 mm 7-10 years; 3-4 tubular adenomas <10 mm 3-5 years; 5-10 tubular adenomas <10 mm, any adenoma ≥10 mm, or adenoma with tubulovillous/villous histology or high-grade dysplasia 3 years; >10 adenomas 1 year with polyposis evaluation; and for serrated polyps, 1-2 sessile serrated lesions <10 mm 5-10 years, 3-4 sessile serrated lesions <10 mm or a hyperplastic polyp ≥10 mm 3-5 years, and a sessile serrated lesion ≥10 mm or with dysplasia or a traditional serrated adenoma 3 years), and apply the shortest interval indicated when findings are mixed. Confirm complete resection and adequate prep before applying an interval, and use site-check/tumor-board pathways for piecemeal resection and malignant (T1) polyps. Refer for genetic evaluation when Lynch, FAP/AFAP/MAP, or serrated polyposis syndrome criteria are met.

Perform individual gastric risk assessment and staging of precancerous conditions at first-time gastroscopy, irrespective of the patient's country of origin. Use high quality endoscopy with virtual chromoendoscopy (VCE), after proper training, for screening, diagnosis and staging of atrophy and intestinal metaplasia and after endoscopic therapy; VCE guides the biopsy site, with random biopsies taken only when there are no endoscopically suspected changes. Take biopsies from at least two topographic sites, 2 from the antrum/incisura and 2 from the corpus, VCE-guided, in two separate, clearly labeled vials; an additional incisura biopsy is optional, not required. Stage with validated endoscopic classifications of atrophy (e.g. Kimura-Takemoto) or intestinal metaplasia (e.g. EGGIM) to stratify gastric cancer risk (suggestion, weaker than the biopsy recommendation). Follow up patients with extensive endoscopic changes (Kimura C3+ or EGGIM 5+) OR an advanced histological stage that reaches OLGA/OLGIM III/IV, severe atrophy or intestinal metaplasia and/or significant changes in both antrum and corpus rising to stage III/IV, not any intestinal metaplasia or any antrum-plus-corpus involvement on its own, with high quality endoscopy every 3 years, irrespective of country of origin (strong recommendation, moderate quality). Propose NO surveillance for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history of gastric cancer, incomplete intestinal metaplasia, persistent H. pylori infection), the guideline states this group constitutes most individuals found in clinical practice. Eradicate H. pylori in all patients with precancerous conditions and after endoscopic or surgical therapy. Discontinue or do not start gastric cancer screening or surveillance in asymptomatic individuals over 80, and weigh comorbidities when planning treatment of superficial lesions. Advise smoking cessation; low-dose daily aspirin may be considered for gastric cancer prevention only in selected individuals already at high cardiovascular risk. For visible neoplasia, use ESD for differentiated lesions clinically staged as dysplastic (low or high grade) or intramucosal carcinoma (any size if not ulcerated, or ≤30 mm if ulcerated), with EMR an alternative for Paris 0-IIa lesions ≤10 mm with low likelihood of malignancy. At the population level, endoscopic screening is suggested every 2-3 years in high-risk regions (age-standardized rate >20 per 100,000 person-years), every 5 years in intermediate-risk regions (ASR 10-20) only if cost-effectiveness has been proven, and not at all in low-risk regions (ASR <10).