Utilization of access to colorectal cancer screening modalities in low-income populations after medicaid expansion

BACKGROUND Colorectal cancer(CRC)remains a relevant public health problem.Current research suggests that racial,economic and geographic disparities impact access.Despite the expansion of Medicaid eligibility as a key component of the Affordable Care Act(ACA),there is a dearth of information on the utilization of newly gained access to CRC screening by low-income individuals.This study investigates the impact of the ACA’s Medicaid expansion on utilization of the various CRC screening modalities by low-income participants.Our working hypothesis is that Medicaid expansion will increase access and utilization of CRC screening by low-income participants.AIM To investigate the impact of the Affordable Care Act and in particular the effect of Medicaid expansion on access and utilization of CRC screening modalities by Medicaid state expansion status across the United States.METHODS This was a quasi-experimental study design using data from the Behavioral Risk Factor Surveillance System,a large health system survey for participants across the United States and with over 2.8 million responses.The period of the study was from 2011 to 2016 which was dichotomized as pre-ACA Medicaid expansion(2011-2013)and post-ACA Medicaid expansion(2014-2016).The change in utilization of access to CRC screening strategies between the expansion periods were analyzed as the dependent variables.Secondary analyses included stratification of the access by ethnicity/race,income,and education status.RESULTS A greater increase in utilization of access to CRC screening was observed in Medicaid expansion states than in nonexpansion states[+2.9%;95%confidence interval(95%CI):2.12,3.69].Low-income participants showed a+4.02%(95%CI:2.96,5.07)change between the expansion periods compared with higher income groups+3.19%(1.70,4.67).Non-Hispanic Whites and Hispanics[+3.01%(95%CI:2.16,3.85)vs+5.51%(95%CI:2.81,8.20)]showed a statistically significant increase in utilization of access but not in Non-Hispanic Blacks,or Multiracial.There was an increase in utilization across all educational levels.This was significant among those who reported having a high school graduate degree or more+4.26%(95%CI:3.16,5.35)compared to some high school or less+1.59%(95%CI:-1.37,4.55).CONCLUSION Medicaid expansion under the Affordable Care Act led to an overall increase in self-reported use of CRC screening tests by adults aged 50-64 years in the United States.This finding was consistent across all low-income populations,but not all races or levels of education.

Molecular methods for colorectal cancer screening:Progress with next-generation sequencing evolution

Currently,colorectal cancer(CRC)represents the third most common malignancy and the second most deadly cancer worldwide,with a higher incidence in developed countries.Like other solid tumors,CRC is a heterogeneous genomic disease in which various alterations,such as point mutations,genomic rearrangements,gene fusions or chromosomal copy number alterations,can contribute to the disease development.However,because of its orderly natural history,easily accessible onset location and high lifetime incidence,CRC is ideally suited for preventive intervention,but the many screening efforts of the last decades have been compromised by performance limitations and low penetrance of the standard screening tools.The advent of next-generation sequencing(NGS)has both facilitated the identification of previously unrecognized CRC features such as its relationship with gut microbial pathogens and revolutionized the speed and throughput of cataloguing CRC-related genomic alterations.Hence,in this review,we summarized the several diagnostic tools used for CRC screening in the past and the present,focusing on recent NGS approaches and their revolutionary role in the identification of novel genomic CRC characteristics,the advancement of understanding the CRC carcinogenesis and the screening of clinically actionable targets for personalized medicine.

Colorectal cancer screening:The role of CT colonography

Computed tomography colonography(CTC) in colorectal cancer(CRC) screening has two roles:one present and the other potential.The present role is,without any further discussion,the integration into established screening programs as a replacement for barium enema in the case of incomplete colonoscopy.The potential role is the use of CTC as a first-line screening method together with Fecal Occult Blood Test,sigmoidoscopy and colonoscopy.However,despite the fact that CTC has been officially endorsed for CRC screening of average-risk individuals by different scientif ic societies including the American Cancer Society,the American College of Radiology,and the US Multisociety Task Force on Colorectal Cancer,other entities,such as the US Preventive Services Task Force,have considered the evidence insuff icient to justify its use as a mass screening method.Medicare has also recently denied reimbursement for CTC as a screening test.Nevertheless,multiple advantages exist for using CTC as a CRC screening test:high accuracy,full evaluation of the colon in virtually all patients,non-invasiveness,safety,patient comfort,detection of extracolonic findings and cost-effectiveness.The main potential drawback of a CTC screening is the exposure to ionizing radiation.However,this is not a major issue,since low-dose protocols are now routinely implemented,delivering a dose comparable or slightly superior to the annual radiation exposure of any individual.Indirect evidence exists that such a radiation exposure does not induce additional cancers.

New endoscopy advances to refine adenoma detection rate for colorectal cancer screening:None is the winner

Colorectal cancer(CRC) is the third most common cancer in males and second in females, and globally the fourth cause for cancer death worldwide. Oncological screening of CRC has a major role in the management of the disease and it is mostly performed by colonoscopy. Anyway, effectiveness of endoscopic screening for CRC strictly depends on adequate detection and removal of potentially precancerous lesions, and accuracy of colonoscopy in detection of adenomas is still suboptimal. For this reason, several technological advances have been implemented in order to improve the diagnostic sensitivity of colonoscopy in adenoma detection. Among these:(1) Visual technologies such as chromoendoscopy and narrow band imaging;(2) optical innovation as high definition endoscopy, full-spectrum endoscopy or Third Eye Retroscope; and(3) mechanical advances as Cap assisted colonoscopy, Endocuff, Endoring and G-Eye endoscope. All these technologies advances have been tested over time by clinical studies with mixed results. Which of them is more likely to be successful in the next future?

Facilitators and barriers to colorectal cancer screening in an outpatient setting

BACKGROUND Colorectal cancer(CRC)is the third most common cancer and the second leading cause of cancer-related deaths in the United States.Still,1 in 3 adults aged 50 years to 75 years have not been screened for CRC.Early detection and management of precancerous or malignant lesions has been shown to improve overall mortality.AIM To determine the most significant facilitators and barriers to CRC screening in an outpatient clinic in rural North Carolina.The results of this study can then be used for quality improvement to increase the rate of patients ages 50 to 75 who are up to date on CRC screening.METHODS This retrospective study examined 2428 patients aged 50 years to 75 years in an outpatient clinic.Patients were up to date on CRC screening if they had fecal occult blood test or fecal immunochemical test in the past one year,Cologuard in the past three years,flexible sigmoidoscopy/virtual colonoscopy in the past five years,or colonoscopy in the past ten years.Data on patient socioeconomic status,comorbid conditions,and other determinants of health compliance were included as covariates.RESULTS Age[odds ratio(OR)=1.058;P=0.017],no-show rate percent(OR=0.962;P<0.05),patient history of obstructive sleep apnea(OR=1.875;P=0.025),compliance with flu vaccinations(OR=1.673;P<0.05),compliance with screening mammograms(OR=2.130;P<0.05),and compliance with screening pap smears(OR=2.708;P<0.05)were important factors in determining whether a patient will receive CRC screening.Race,gender,insurance or employment status,use of blood thinners,family history of CRC,or other comorbid conditions including diabetes,hypertension,congestive heart failure,chronic obstructive pulmonary disease,and end-stage renal disease were not found to have a statistically significant effect on patient adherence to CRC screening.CONCLUSION Patient age,history of sleep apnea,and compliance with other health maintenance tests were significant facilitators to CRC screening,while no-show rate percent was a significant barrier in our patient population.This study will be of benefit to physicians in addressing and improving the CRC screening rates in our community.

How the COVID-19 pandemic has affected the colorectal cancer screening in Italy:A minireview

The coronavirus disease 2019(COVID-19)pandemic has caused detrimental effects on many aspects of healthcare practice.Screening programs for the commonest malignancies,namely colorectal cancer(CRC),breast cancer and cervical cancer have been discontinued or interrupted since the beginning of restriction measures aimed to limit transmission of the new coronavirus infection.Robust evidence exists in favour of the role of screening campaigns in reducing mortality from CRC.In fact,the majority of pre-malignant lesions of the colon and rectum can be diagnosed with colonoscopy and treated by endoscopic or surgical resection.Besides,colonoscopy screening allows the diagnosis of CRCs in their pre-clinical stage.Italy was one of the first European countries where a high level of COVID-19 infections and deaths was observed,and one of the first where lockdowns and strict measures were adopted to reduce the risk of COVID-19 diffusion among the population.A systematic review of the literature was performed,including the PubMed,Scopus,Web of Sciences,and Reference Citation Analysis databases,with the aim of critically evaluating the impact of the COVID-19 pandemic on CRC screening in Italy.We found that reduction of CRC screening activity surpassed 50%in most endoscopic units,with almost 600000 fewer CRC screening exams conducted in the first 5 mo of 2020 vs the same period of 2019.While the consequences of the discontinuation of endoscopy screening for the prognosis and mortality of CRC will be evident in the next few years,recent data confirm that CRC is currently treated at a more advanced stage than in the pre-COVID-19 era.Since delays in CRC prevention and early diagnosis may translate to increased CRC-specific mortality,world healthcare systems should adopt strategies to maintain the regularity of CRC screening during subsequent peaks of the COVID-19 pandemic,or future events that might hamper screening programs.

Supply and quality of colonoscopy according to the characteristics of gastroenterologists in the French population-based colorectalcancer screening program

BACKGROUND Since its complete roll-out in 2009,the French colorectal cancer screening program(CRCSP)experienced 3 major constraints[use of a less efficient Guaiac-test(gFOBT),stopping the supply of Fecal-Immunochemical-Test kits(FIT),and suspension of the program due to the coronavirus disease 2019(COVID-19)]affecting its effectiveness.AIM To describe the impact of the constraints in terms of changes in the quality of screeningcolonoscopy(Quali-Colo).METHODS This retrospective cohort study included screening-colonoscopies performed by gastroenterologists between Jan-2010 and Dec-2020 in people aged 50-74 living in Ile-de-France(France).The changes in Quali-colo(Proportion of colonoscopies performed beyond 7 mo(Colo_7 mo),Frequency of serious adverse events(SAE)and Colonoscopy detection rate)were described in a cohort of Gastroenterologists who performed at least one colonoscopy over each of the four periods defined according to the chronology of the constraints[gFOBT:Normal progress of the CRCSP using gFOBT(2010-2014);FIT:Normal progress of the CRCSP using FIT(2015-2018);STOP-FIT:Year(2019)during which the CRCSP experienced the cessation of the supply of test kits;COVID:Program suspension due to the COVID-19 health crisis(2020)].The link between each dependent variable(Colo_7 mo;SAE occurrence,neoplasm detection rate)and the predictive factors was analyzed in a two-level multivariate hierarchical model.RESULTS The 533 gastroenterologists(cohort)achieved 21509 screening colonoscopies over gFOBT period,38352 over FIT,7342 over STOP-FIT and 7995 over COVID period.The frequency of SAE did not change between periods(gFOBT:0.3%;FIT:0.3%;STOP-FIT:0.3%;and COVID:0.2%;P=0.10).The risk of Colo_7 mo doubled between FIT[adjusted odds ratio(aOR):1.2(1.1;1.2)]and STOPFIT[aOR:2.4(2.1;2.6)];then,decreased by 40%between STOP-FIT and COVID[aOR:2.0(1.8;2.2)].Regardless of the period,this Colo_7 mo’s risk was twice as high for screening colonoscopy performed in a public hospital[aOR:2.1(1.3;3.6)]compared to screening-colonoscopy performed in a private clinic.The neoplasm detection,which increased by 60%between gFOBT and FIT[aOR:1.6(1.5;1.7)],decreased by 40%between FIT and COVID[aOR:1.1(1.0;1.3)].CONCLUSION The constraints likely affected the time-to-colonoscopy as well as the colonoscopy detection rate without impacting the SAE’s occurrence,highlighting the need for a respectable reference time-tocolonoscopy in CRCSP.

Why is early detection of colon cancer still not possible in 2023?

Colorectal cancer(CRC)screening is a fundamental tool in the prevention and early detection of one of the most prevalent and lethal cancers.Over the years,screening,particularly in those settings where it is well organized,has succeeded in reducing the incidence of colon and rectal cancer and improving the prognosis related to them.Despite considerable advancements in screening technologies and strategies,the effectiveness of CRC screening programs remains less than optimal.This paper examined the multifaceted reasons behind the persistent lack of effect-iveness in CRC screening initiatives.Through a critical analysis of current methodologies,technological limitations,patient-related factors,and systemic challenges,we elucidated the complex interplay that hampers the successful reduction of CRC morbidity and mortality rates.While acknowledging the ad-vancements that have improved aspects of screening,we emphasized the necessity of addressing the identified barriers comprehensively.This study aimed to raise awareness of how important CRC screening is in reducing costs for this disease.Screening and early diagnosis are not only important in improving the prognosis of patients with CRC but can lead to an important reduction in the cost of treating a disease that is often diagnosed at an advanced stage.Spending more sooner can mean saving money later.

Missed colorectal cancers in a fecal immunochemical test-based screening program: Molecular profiling of interval carcinomas

BACKGROUND For optimizing fecal immunochemical test(FIT)-based screening programs,reducing the rate of missed colorectal cancers(CRCs)by FIT(FIT-interval CRCs)is an important aspect.Knowledge of the molecular make-up of these missed lesions could facilitate more accurate detection of all(precursor)lesions.AIM To compare the molecular make-up of FIT-interval CRCs to lesions that are detected by FIT[screen-detected CRCs(SD-CRCs)].METHODS FIT-interval CRCs observed in a Dutch pilot-program of FIT-based screening were compared to a control group of SD-CRCs in a 1:2 ratio,resulting in 27 FIT-interval CRC and 54 SD-CRCs.Molecular analyses included microsatellite instability(MSI),CpG island methylator phenotype(CIMP),DNA sequence mutations and copy number alterations(CNAs).RESULTS Although no significant differences were reached,FIT-interval CRCs were more often CIMP positive and MSI positive(33%CIMP in FIT-interval CRCs vs 21%in SD-CRCs(P=0.274);19%MSI in FIT-interval CRCs vs 12%in SD-CRCs(P=0.469)),and showed more often serrated pathway associated features such as BRAF(30%vs 12%,P=0.090)and PTEN(15%vs 2.4%,P=0.063)mutations.APC mutations,a classic feature of the adenoma-carcinoma-sequence,were more abundant in SD-CRCs(68%vs 40%in FIT-interval CRCs P=0.035).Regarding CNAs differences between the two groups;FIT-interval CRCs less often showed gains at the regions 8p11.22-q24.3(P=0.009),and more often gains at 20p13-p12.1(P=0.039).CONCLUSION Serrated pathway associated molecular features seem to be more common in FIT-interval CRCs,while classic adenoma carcinoma pathway associated molecular features seem to be more common in SD-CRCs.This indicates that proximal serrated lesions may be overrepresented among FITinterval CRCs.

Biomarkers for detecting colorectal cancer non-invasively: DNA,RNA or proteins?

Colorectal cancer(CRC)is a global problem affecting millions of people worldwide.This disease is unique because of its slow progress that makes it preventable and often curable.CRC symptoms usually emerge only at advanced stages of the disease,consequently its early detection can be achieved only through active population screening,which markedly reduces mortality due to this cancer.CRC screening tests that employ non-invasively detectable biomarkers are currently being actively developed and,in most cases,samples of either stool or blood are used.However,alternative biological substances that can be collected non-invasively(colorectal mucus,urine,saliva,exhaled air)have now emerged as new sources of diagnostic biomarkers.The main categories of currently explored CRC biomarkers are:(1)Proteins(comprising widely used haemoglobin);(2)DNA(including mutations and methylation markers);(3)RNA(in particular microRNAs);(4)Low molecular weight metabolites(comprising volatile organic compounds)detectable by metabolomic techniques;and(5)Shifts in gut microbiome composition.Numerous tests for early CRC detection employing such non-invasive biomarkers have been proposed and clinically studied.While some of these studies generated promising early results,very few of the proposed tests have been transformed into clinically validated diagnostic/screening techniques.Such DNA-based tests as Food and Drug Administration-approved multitarget stool test(marketed as Cologuard®)or blood test for methylated septin 9(marketed as Epi proColon®2.0 CE)show good diagnostic performance but remain too expensive and technically complex to become effective CRC screening tools.It can be concluded that,despite its deficiencies,the protein(haemoglobin)detection-based faecal immunochemical test(FIT)today presents the most cost-effective option for non-invasive CRC screening.The combination of non-invasive FIT and confirmatory invasive colonoscopy is the current strategy of choice for CRC screening.However,continuing intense research in the area promises the emergence of new superior non-invasive CRC screening tests that will allow the development of improved disease prevention strategies.

Colorectal cancer of the young displays distinct features of aggressive tumor biology:A single-center cohort study

BACKGROUND In recent years,a decrease in incidence and mortality of colorectal cancer(CRC)has been observed in developed nations,presumably through public disease awareness and increased screening efforts.However,a rising incidence of CRC in young patients below the age of 50 years has been reported in several studies.AIM To study tumor biology in CRC patients below 50 years of age.METHODS All patients with CRC were prospectively enrolled in our single-center oncologic database from January 2013 to December 2018 and were grouped and analyzed according to age(≥50 and<50 years).Clinical as well as histopathological features were analyzed and compared.The study was approved by the local Ethics Committee.Fisher’s exact test or t-test was used to test for differences between the groups,as appropriate.All statistical analysis was performed with IBM SPSS software Version 25(SPSS Inc,Armonk,NY,United States)and with RStudio using R Version 3.4.1(RStudio,Boston,MA,United States).RESULTS Seventeen percent of the 411 patients were younger than 50 years.Young patients were more often diagnosed with locally advanced T4-tumors and lymph node metastases(36.6%and 62%vs 17.7%and 42%;P<0.01).In addition,a higher frequency of poorly differentiated(G3)tumors(40%vs 22.4%P<0.05)was observed.More than every second patient below 40 years of age(51.8%)had distant metastases at diagnosis with a significant higher rate ring of signet cell differentiation compared to patients≥50 years(14.8%,P<0.05).Mutational status(KRAS,NRAS,BRAF,MSI)as well as selected behavioral risk factors showed no significant differences.CONCLUSION Distinct histopathologic features of increased biologic aggressiveness are found in patients with CRC of young-onset.Those patients present more frequently with more advanced tumor stages compared to older patients.Features of aggressive tumor biology underscore the need for earlier uptake of routine screening measures.

Prediction of the severity of colorectal lesion by fecal hemoglobin concentration observed during previous test in the French screening program

BACKGROUND The rate of positive tests using fecal immunochemical test(FIT)does not decrease with subsequent campaigns,but the positive predictive value of advanced neoplasia significantly decreases in subsequent campaign after a first negative test.A relationship between the fecal hemoglobin concentration(Fhb)and the opportunity to detect a colorectal cancer in subsequent campaign has been shown.AIM To predict the severity of colorectal lesions based on Fhb measured during previous colorectal cancer screening campaign.METHODS This etiological study included 293750 patients aged 50-74,living in Auvergne-Rhone-Alpes(France).These patients completed at least two FIT[test_((-1))and test_((0))]between June 2015 and December 2019.Delay between test_((-1))and test_((0))was>1year and test_((-1))result was negative(<150 ngHb/mL).The severity of colorectal lesions diagnosed at test_((0))was described according to Fhb measured at test_((-1))[Fhb_((-1))].The relationship between the severity classified in seven ordinal categories and the predictive factors was analyzed in an ordered multivariate polytomous regression model.RESULTS The test_((0))positive rate was 4.0%,and the colonoscopy completion rate was 97.1%in 11594 patients who showed a positive test_((0)).The colonoscopy detection rate was 77.7%in those 11254 patients who underwent a colonoscopy.A total of 8748 colorectal lesions were detected(including 2182 low-risk-polyps,2400 high-riskpolyp,and 502 colorectal cancer).The colonoscopy detection rate varied significantly with Fhb_((-1))[0 ngHb/mL:75.6%,(0-50 ngHb/mL):77.3%,(50-100 ngHb/mL):88.7%,(100-150 ngHb/mL):90.3%;P=0.001].People with a Fhb_((-1))within(100-150 ngHb/mL)(P=0.001)were 2.6(2.2;3.0)times more likely to have a high severity level compared to those having a Fhb_((-1))value of zero.This risk was reduced by 20%in patients aged 55-59 compared to those aged<55[adjusted odds ratio:0.8(0.6;1.0)].CONCLUSION The study showed that higher Fhb_((-1))is correlated to an increased risk of severity of colorectal lesions.This risk of severity increased among first-time participants(age<55)and the elderly(≥70).To avoid the loss of chance in these age groups,the FIT positivity threshold should be reduced to 100 ngHb/mL.The other alternative would be to reduce the time between the two tests in these age groups from the current 2 years to 1 year.

A path for diagnosis and therapy of colon cancer: a continuous quality improvement

Objective： Prognosis of colorectal cancer strongly depends on stage at diagnosis, which can be cured in most cases at an early stage. The results were supported by different screening programmes. Few data concerning analysis of different phases of Colorectal Cancer Program were reported in literature. The aim of this study is to analyze ＂step by step＂, from a longitudinal type, the Colorectal Cancer Program, active at our Institution, verifying compliance with standards of care.Methods： We compared two different populations during the same period： patients referring to our Clinical Oncology Unit coming from Regional Colorectal Cancer Screening Program and the other population that was not in any Colorectal Cancer Program.Results： Considering patients from the Regional Colorectal Cancer Screening Program（19 patients, corresponding to 24.0% of the general case study）, 3（15.8%） were deceased and 16（84.2%） were alive without evidence of the disease（NED）. Concerning patients that are not coming from Regional Colorectal Cancer Screening Program（61 patients, corresponding to 76.0% of the general case study）, 9（14.8%） were deceased, 43（70.5%） were NED, 8（13.1%） were alive with metastases and 1（1.6%） was lost during follow-up（PFU）. Conclusions： On the basis of this experience, we concluded for high-quality care for both populations. Any critical point should be carefully analyzed in order to implement quality of care.

Serrated lesions:A challenging enemy

The serrated pathway accounts for 30%-35%of colorectal cancer(CRC).Unlike hyperplastic polyps,both sessile serrated lesions(SSLs)and traditional serrated adenomas are premalignant lesions,yet SSLs are considered to be the principal serrated precursor of CRCs.Serrated lesions represent a challenge in detection,classification,and removal–contributing to post-colonoscopy cancer.Therefore,it is of the utmost importance to characterize these lesions properly to ensure complete removal.A retrospective cohort study developed a diagnostic scoring system for SSLs to facilitate their detection endoscopically and subsequent removal.From the study,it can be ascertained that both indistinct border and mucus cap are essential in both recognizing and diagnosing serrated lesions.The proximal colon poses technical challenges for some endoscopists,which is why high-quality colonoscopy plays such an important role.The indistinct border of some SSLs poses another challenge due to difficult complete resection.Overall,it is imperative that gastroenterologists use the key features of mucus cap,indistinct borders,and size of at least five millimeters along with a high-quality colonoscopy and a good bowel preparation to improve the SSL detection rate.

Improving sessile serrated adenoma detection rates with high definition colonoscopy:A retrospective study

BACKGROUND Sessile serrated adenomas(SSAs)are important premalignant lesions that are difficult to detect during colonoscopy due to poor definition,concealment by mucous caps,and flat appearance.High definition(HD)colonoscopy may uniquely aid in the detection of these inconspicuous lesions compared to standard definition(SD)colonoscopes.In the absence of existing clinical guidelines to obligate the use of HD colonoscopy for colorectal cancer screening in average-risk patients,demonstrating the benefit of HD colonoscopy on SSA detection rate(SSADR)may help strengthen the evidence to recommend its use in all settings.AIM To evaluate the benefit of HD colonoscopy compared to SD colonoscopy on SSADR in average-risk patients undergoing screening colonoscopy.METHODS Data from screening colonoscopies for patients aged 50-76 years two years before and two years after the transition from SD colonoscopy to HD colonoscopy at our large,academic teaching center were collected.Patients with symptoms of colorectal disease,positive occult blood test,history of colon polyps,cancer,polyposis syndrome,inflammatory bowel disease or family history of colon cancer or polyps were excluded.Patients whose endoscopists did not perform colonoscopies both before and after scope definition change were also excluded.Differences in individual endoscopist SSADR,average SSADR,and overall SSADR with SD colonoscopy vs HD colonoscopy were also evaluated for significance.RESULTS A total of 3657 colonoscopies met eligibility criteria with 2012 colonoscopies from the SD colonoscopy period and 1645 colonoscopies from the HD colonoscopy period from a pool of 11 endoscopists.Statistically significant improvements of 2.30%in mean SSADR and 2.53%in overall SSADR were noted with HD colonoscopy(P=0.00028 and P=0.00849,respectively).On the individual level,three endoscopists experienced statistically significant benefit with HD colonoscopy(+5.74%,P=0.0056;+4.50%,P=0.0278;+4.84%,P=0.03486).CONCLUSION Our study suggests that HD colonoscopy statistically significantly improves sessile serrated adenoma detection rate in the screening of average risk patients during screening colonoscopy.By improving the detection and removal of these lesions,adoption of HD colonoscopy may reduce the significant premalignant burden of sessile serrated adenomas.