Demographic and Clinicopathologic Risk Factors for Colorectal Adenoma Recurrence: A Large-Scale Surveillance Cohort Study of 59,667 Adults.

Abstract

Background: Current colorectal surveillance guidelines emphasize adenoma characteristics but overlook temporal, racial, and sex-based heterogeneity in recurrence risk- an gap that limits equitable and personalized care. To evaluate the associations of demographic factors, obesity, and adenoma features with recurrence risk over time in a large longitudinal surveillance cohort.

Methods: This retrospective cohort study included 59,667 adults who underwent their first colonoscopic polypectomy between January 1990 and July 2024 at a tertiary medical center. Median follow-up was 4 years. Demographic variables included race and ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic, Asian or Pacific Islander [API]), sex, obesity (BMI >30), family history of colorectal cancer (CRC) or polyps, and age at adenoma onset (<50 vs ≥50 years). Adenoma features included histology, size, number, and dysplasia. The primary outcome was recurrence-free survival, defined as time from initial polypectomy to histologically confirmed recurrence. Cox proportional hazards models estimated associations adjusted for confounders, with stratified analyses over 5-, 10-, and >10-year follow-up intervals.

Findings: Among 59,667 patients, 17,596 (29.5%) experienced recurrence within 5 years, revealing substantial temporal heterogeneity. Early recurrence was associated with male sex (adjusted hazard ratio [aHR], 1.10; 95% CI, 1.06-1.14), obesity (aHR, 1.18; 95% CI, 1.13-1.23), early-onset adenomas (aHR, 1.17; 95% CI, 1.11-1.23), and family history of CRC (aHR, 1.24; 95% CI, 1.18-1.31). Compared with NHW patients, NHB individuals had lower early recurrence risk (aHR, 0.89; 95% CI, 0.83-0.96) but higher late recurrence (>10 years; aHR, 1.26; 95% CI, 1.06-1.50). API patients had a similar shift, with lower early risk (aHR, 0.80; 95% CI, 0.67- 0.96) and elevated mid-term risk (5-10 years; aHR, 1.40; 95% CI, 1.08-1.81). High-grade dysplasia (aHR 2.86; 95% CI, 2.54-3.22) and villous histology (aHR 2.55; 95% CI, 2.31-2.81showed the largest effect sizes for early recurrence. Females had stronger associations with tubulovillous histology, mixed adenomas, and large lesions.

Interpretation: Temporal, demographic, and histologic differences in adenoma recurrence highlight the need for surveillance strategies that incorporate population- and time-specific risk profiles to enhance colorectal cancer prevention.

Funding: This work was supported by the National Cancer Institute (Grant No. R37CA227130 to Xingyi Guo).

Research in context: Evidence before this study: We conducted a PubMed search for publications dated before June 2024 using combinations of keywords such as "colonoscopic polypectomy," "Demographic and Clinicopathologic Risk Factors," "Vannderbilt," and "electronic health records." We found no studies that comprehensively evaluated the associations of demographic characteristics, obesity, and adenoma features with recurrence risk over time in a large, longitudinal surveillance cohort.Added Value of This Study: Using a longitudinal cohort of 59,667 patients, our study reveals substantial temporal heterogeneity in adenoma recurrence. Non-Hispanic Black and Asian or Pacific Islander individuals exhibited a lower risk of recurrence within the first 5 years but experienced increased risk at 5-10 and >10 years post-polypectomy. Females showed heightened early recurrence risk, particularly when initial adenomas were tubulovillous, mixed-type, or large. Early recurrence was predominantly driven by high-grade dysplasia, high-risk adenomas, villous or tubulovillous histology, and multiplicity.Implications of All the Available Evidence: These findings highlight the critical need to recognize and address temporal, racial, and sex-specific heterogeneity in adenoma recurrence risk. The observed variability in histopathologic and demographic factors over time underscores the importance of personalized, adaptive surveillance strategies to reduce adenoma recurrence and enhance colorectal cancer prevention.