Feature

Even though older adults are more likely to be diagnosed with colorectal cancer (CRC), there is a concerning rise in diagnoses among younger adults, making it essential for healthcare providers to educate adult patients of all ages about the lifestyle-related risk factors associated with the disease.

Many are familiar with the modifiable risk factors of obesity, smoking, and alcohol consumption, but the impact of processed meat — a common element of the Western diet —often remains underappreciated.

But the data are clear: Processed meat, defined as meat that has been altered through methods such as salting, curing, fermentation, or smoking to enhance flavor or preservation, has been linked to an increased risk for CRC.

The International Agency for Research on Cancer, part of the World Health Organization, analyzed over 800 global studies and classified processed meats as carcinogenic to humans, whereas red meat was deemed “probably” carcinogenic. Their findings were later published in The Lancet Oncology, confirming that the strongest epidemiological evidence linked processed meat consumption to CRC.

“While I routinely counsel my patients about lifestyle and dietary risk factors for CRC, including processed meat, I’m not sure how often this is specifically mentioned by physicians in practice,” Peter S. Liang, MD, MPH, an assistant professor and researcher focused on CRC prevention at NYU Langone Health in New York City, and an AGA spokesperson, told GI & Hepatology News.

David A. Johnson, MD, chief of gastroenterology at Eastern Virginia Medical School and Old Dominion University, both in Norfolk, Virginia, concurred.

Many healthcare providers may not fully recognize the risks posed by processed meat in relation to CRC to counsel their patients, Johnson said. “In my experience, there is not a widespread awareness.”

 

Understanding the Carcinogenic Risks 

The excess risk for CRC per gram of intake is higher for processed meat than for red meat. However, the threshold for harmful consumption varies among studies, and many group red and processed meat together in their analyses.

For example, a 2020 prospective analysis of UK Biobank data reported that a 70 g/d higher intake of red and processed meat was associated with a 32% and 40% greater risk for CRC and colon cancer, respectively.

More recently, a 2025 prospective study examined the associations between CRC and 97 dietary factors in 542,778 women. Investigators found that, aside from alcohol, red and processed meat were the only other dietary factors positively associated with CRC, with a 30 g/d intake increasing the risk for CRC by 8%.

Although the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) recommend limiting red meat consumption to no more than three portions a week, their guidance on processed meat is simpler and more restrictive: Consume very little, if any.

The risk for CRC associated with processed meats is likely due to a naturally occurring element in the meat and carcinogenic compounds that are added or created during its preparation, Johnson said.

Large bodies of evidence support the association between certain compounds in processed meat and cancer, added Ulrike Peters, PhD, MPH, professor and associate director of the Public Health Sciences Division at the Fred Hutchinson Cancer Center in Seattle.

These compounds include:

• Heterocyclic amines: Prevalent in charred and well-done meat, these chemicals are created from the reaction at high temperatures between creatine/creatinine, amino acids, and sugars.
• Nitrates/nitrites: Widely used in the curing of meat (eg, sausages, ham, bacon) to give products their pink coloring and savory flavor, these inorganic compounds bind with amines to produce N-nitrosamines, among the most potent genotoxic carcinogens.
• Polycyclic aromatic hydrocarbons: Generated during high-temperature cooking and smoking, these compounds can induce DNA damage in the colon.
• Heme iron: This type of iron, abundant in red and processed meats, promotes formation of carcinogenic N-nitroso compounds and oxidative damage to intestinal tissue.

Peters said that the compounds may work synergistically to increase the risk for CRC through various mechanisms, including DNA damage, inflammation, and altered gut microbiota.

While it would be useful to study whether the different meat-processing methods — for example, smoking vs salting — affect CRC risk differently, “practically, this is difficult because there’s so much overlap,” Liang noted.

 

Risk Mitigation

Lifestyle factors likely play a crucial role in the risk for CRC. For example, a study of European migrants to Australia found that those from countries with lower CRC incidences tended to develop a higher risk for CRC the longer they resided in Australia due to the dietary change.

Understanding how to mitigate these risk factors is becoming increasingly important with the rates of early-onset CRC projected to double by 2030 in the United States, a trend that is also being observed globally.

“With early-onset CRC, it’s becoming quite clear that there’s no single risk factor that’s driving this increase,” Liang said. “We need to look at the risk factors that we know cause CRC in older adults and see which have become more common over time.”

The consumption of processed meats is one such factor that’s been implicated, particularly for early-onset CRC. The average global consumption of all types of meat per capita has increased significantly over the last 50 years. A 2022 report estimated that global mean processed meat consumption was 17 g/d, with significantly higher rates in high-income regions. This number is expected to rise, with the global processed meat market projected to grow from $318 billion in 2023 to $429 billion by 2029. Given this, the importance of counseling patients to reduce their meat intake is further underscored.

Another strategy for mitigating the risks around processed meat is specifically identifying those patients who may be most vulnerable.

In 2024, Peters and colleagues published findings from their genome-wide gene-environment interaction analysis comparing a large population with CRC and healthy control individuals. The research identified two novel biomarkers that support the role of red and processed meat with an increased risk for CRC and may explain the higher risk in certain population subgroups. They are working on genetic risk prediction models that will incorporate these genetic markers but must first ensure robust validation through larger studies.

“This approach aligns with precision medicine principles, allowing for more personalized prevention strategies, though we’re not quite there yet in terms of clinical application,” Peters said.

Another knowledge gap that future research efforts could address is how dietary factors influence survival outcomes after a diagnosis of CRC.

“The existing guidelines primarily focus on cancer prevention, with strong evidence linking processed meat consumption to increased CRC risk. However, the impact of dietary choices on survival after CRC diagnosis remains poorly understood,” Peters said. “This distinction between prevention and survival is crucial, as biological mechanisms and optimal dietary interventions may differ significantly between these two contexts.”

Well-designed studies investigating the relationship between dietary patterns and CRC survival outcomes would enable the development of evidence-based nutritional recommendations specifically tailored for CRC survivors, Peters said. In addition, she called for well-designed studies that compare levels of processed meat consumption between cohorts of patients with early-onset CRC and healthy counterparts.

“This would help establish whether there’s a true causal relationship rather than just correlation,” Peters said.

 

Simple Strategies to Dietary Changes

With a 2024 study finding that greater adherence to WCRF/AICR Cancer Prevention Recommendations, including reducing processed meat consumption, was linked to a 14% reduction in CRC risk, physicians should emphasize the benefits of adopting dietary and lifestyle recommendations to patients.

Johnson advised simple strategies to encourage any needed dietary changes.

“Pay attention to what you eat, proportions, and variation of meal menus. Those are good starter points,” he told GI & Hepatology News. “None of these recommendations related to meats should be absolute, but reduction can be the target.”

Liang stressed the importance of repeated, nonjudgmental discussions.

“Research shows that physician recommendation is one of the strongest motivators in preventive health, so even if it doesn’t work the first few times, we have to continue delivering the message that can improve our patients’ health.”

A version of this article appeared on Medscape.com.

Even though older adults are more likely to be diagnosed with colorectal cancer (CRC), there is a concerning rise in diagnoses among younger adults, making it essential for healthcare providers to educate adult patients of all ages about the lifestyle-related risk factors associated with the disease.

Many are familiar with the modifiable risk factors of obesity, smoking, and alcohol consumption, but the impact of processed meat — a common element of the Western diet —often remains underappreciated.

But the data are clear: Processed meat, defined as meat that has been altered through methods such as salting, curing, fermentation, or smoking to enhance flavor or preservation, has been linked to an increased risk for CRC.

The International Agency for Research on Cancer, part of the World Health Organization, analyzed over 800 global studies and classified processed meats as carcinogenic to humans, whereas red meat was deemed “probably” carcinogenic. Their findings were later published in The Lancet Oncology, confirming that the strongest epidemiological evidence linked processed meat consumption to CRC.

“While I routinely counsel my patients about lifestyle and dietary risk factors for CRC, including processed meat, I’m not sure how often this is specifically mentioned by physicians in practice,” Peter S. Liang, MD, MPH, an assistant professor and researcher focused on CRC prevention at NYU Langone Health in New York City, and an AGA spokesperson, told GI & Hepatology News.

David A. Johnson, MD, chief of gastroenterology at Eastern Virginia Medical School and Old Dominion University, both in Norfolk, Virginia, concurred.

Many healthcare providers may not fully recognize the risks posed by processed meat in relation to CRC to counsel their patients, Johnson said. “In my experience, there is not a widespread awareness.”

 

Understanding the Carcinogenic Risks 

The excess risk for CRC per gram of intake is higher for processed meat than for red meat. However, the threshold for harmful consumption varies among studies, and many group red and processed meat together in their analyses.

For example, a 2020 prospective analysis of UK Biobank data reported that a 70 g/d higher intake of red and processed meat was associated with a 32% and 40% greater risk for CRC and colon cancer, respectively.

More recently, a 2025 prospective study examined the associations between CRC and 97 dietary factors in 542,778 women. Investigators found that, aside from alcohol, red and processed meat were the only other dietary factors positively associated with CRC, with a 30 g/d intake increasing the risk for CRC by 8%.

Although the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) recommend limiting red meat consumption to no more than three portions a week, their guidance on processed meat is simpler and more restrictive: Consume very little, if any.

The risk for CRC associated with processed meats is likely due to a naturally occurring element in the meat and carcinogenic compounds that are added or created during its preparation, Johnson said.

Large bodies of evidence support the association between certain compounds in processed meat and cancer, added Ulrike Peters, PhD, MPH, professor and associate director of the Public Health Sciences Division at the Fred Hutchinson Cancer Center in Seattle.

These compounds include:

• Heterocyclic amines: Prevalent in charred and well-done meat, these chemicals are created from the reaction at high temperatures between creatine/creatinine, amino acids, and sugars.
• Nitrates/nitrites: Widely used in the curing of meat (eg, sausages, ham, bacon) to give products their pink coloring and savory flavor, these inorganic compounds bind with amines to produce N-nitrosamines, among the most potent genotoxic carcinogens.
• Polycyclic aromatic hydrocarbons: Generated during high-temperature cooking and smoking, these compounds can induce DNA damage in the colon.
• Heme iron: This type of iron, abundant in red and processed meats, promotes formation of carcinogenic N-nitroso compounds and oxidative damage to intestinal tissue.

Peters said that the compounds may work synergistically to increase the risk for CRC through various mechanisms, including DNA damage, inflammation, and altered gut microbiota.

While it would be useful to study whether the different meat-processing methods — for example, smoking vs salting — affect CRC risk differently, “practically, this is difficult because there’s so much overlap,” Liang noted.

 

Risk Mitigation

Lifestyle factors likely play a crucial role in the risk for CRC. For example, a study of European migrants to Australia found that those from countries with lower CRC incidences tended to develop a higher risk for CRC the longer they resided in Australia due to the dietary change.

Understanding how to mitigate these risk factors is becoming increasingly important with the rates of early-onset CRC projected to double by 2030 in the United States, a trend that is also being observed globally.

“With early-onset CRC, it’s becoming quite clear that there’s no single risk factor that’s driving this increase,” Liang said. “We need to look at the risk factors that we know cause CRC in older adults and see which have become more common over time.”

The consumption of processed meats is one such factor that’s been implicated, particularly for early-onset CRC. The average global consumption of all types of meat per capita has increased significantly over the last 50 years. A 2022 report estimated that global mean processed meat consumption was 17 g/d, with significantly higher rates in high-income regions. This number is expected to rise, with the global processed meat market projected to grow from $318 billion in 2023 to $429 billion by 2029. Given this, the importance of counseling patients to reduce their meat intake is further underscored.

Another strategy for mitigating the risks around processed meat is specifically identifying those patients who may be most vulnerable.

In 2024, Peters and colleagues published findings from their genome-wide gene-environment interaction analysis comparing a large population with CRC and healthy control individuals. The research identified two novel biomarkers that support the role of red and processed meat with an increased risk for CRC and may explain the higher risk in certain population subgroups. They are working on genetic risk prediction models that will incorporate these genetic markers but must first ensure robust validation through larger studies.

“This approach aligns with precision medicine principles, allowing for more personalized prevention strategies, though we’re not quite there yet in terms of clinical application,” Peters said.

Another knowledge gap that future research efforts could address is how dietary factors influence survival outcomes after a diagnosis of CRC.

“The existing guidelines primarily focus on cancer prevention, with strong evidence linking processed meat consumption to increased CRC risk. However, the impact of dietary choices on survival after CRC diagnosis remains poorly understood,” Peters said. “This distinction between prevention and survival is crucial, as biological mechanisms and optimal dietary interventions may differ significantly between these two contexts.”

Well-designed studies investigating the relationship between dietary patterns and CRC survival outcomes would enable the development of evidence-based nutritional recommendations specifically tailored for CRC survivors, Peters said. In addition, she called for well-designed studies that compare levels of processed meat consumption between cohorts of patients with early-onset CRC and healthy counterparts.

“This would help establish whether there’s a true causal relationship rather than just correlation,” Peters said.

 

Simple Strategies to Dietary Changes

With a 2024 study finding that greater adherence to WCRF/AICR Cancer Prevention Recommendations, including reducing processed meat consumption, was linked to a 14% reduction in CRC risk, physicians should emphasize the benefits of adopting dietary and lifestyle recommendations to patients.

Johnson advised simple strategies to encourage any needed dietary changes.

“Pay attention to what you eat, proportions, and variation of meal menus. Those are good starter points,” he told GI & Hepatology News. “None of these recommendations related to meats should be absolute, but reduction can be the target.”

Liang stressed the importance of repeated, nonjudgmental discussions.

“Research shows that physician recommendation is one of the strongest motivators in preventive health, so even if it doesn’t work the first few times, we have to continue delivering the message that can improve our patients’ health.”

A version of this article appeared on Medscape.com.

Even though older adults are more likely to be diagnosed with colorectal cancer (CRC), there is a concerning rise in diagnoses among younger adults, making it essential for healthcare providers to educate adult patients of all ages about the lifestyle-related risk factors associated with the disease.

Many are familiar with the modifiable risk factors of obesity, smoking, and alcohol consumption, but the impact of processed meat — a common element of the Western diet —often remains underappreciated.

But the data are clear: Processed meat, defined as meat that has been altered through methods such as salting, curing, fermentation, or smoking to enhance flavor or preservation, has been linked to an increased risk for CRC.

The International Agency for Research on Cancer, part of the World Health Organization, analyzed over 800 global studies and classified processed meats as carcinogenic to humans, whereas red meat was deemed “probably” carcinogenic. Their findings were later published in The Lancet Oncology, confirming that the strongest epidemiological evidence linked processed meat consumption to CRC.

“While I routinely counsel my patients about lifestyle and dietary risk factors for CRC, including processed meat, I’m not sure how often this is specifically mentioned by physicians in practice,” Peter S. Liang, MD, MPH, an assistant professor and researcher focused on CRC prevention at NYU Langone Health in New York City, and an AGA spokesperson, told GI & Hepatology News.

David A. Johnson, MD, chief of gastroenterology at Eastern Virginia Medical School and Old Dominion University, both in Norfolk, Virginia, concurred.

Many healthcare providers may not fully recognize the risks posed by processed meat in relation to CRC to counsel their patients, Johnson said. “In my experience, there is not a widespread awareness.”

 

Understanding the Carcinogenic Risks 

The excess risk for CRC per gram of intake is higher for processed meat than for red meat. However, the threshold for harmful consumption varies among studies, and many group red and processed meat together in their analyses.

For example, a 2020 prospective analysis of UK Biobank data reported that a 70 g/d higher intake of red and processed meat was associated with a 32% and 40% greater risk for CRC and colon cancer, respectively.

More recently, a 2025 prospective study examined the associations between CRC and 97 dietary factors in 542,778 women. Investigators found that, aside from alcohol, red and processed meat were the only other dietary factors positively associated with CRC, with a 30 g/d intake increasing the risk for CRC by 8%.

Although the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) recommend limiting red meat consumption to no more than three portions a week, their guidance on processed meat is simpler and more restrictive: Consume very little, if any.

The risk for CRC associated with processed meats is likely due to a naturally occurring element in the meat and carcinogenic compounds that are added or created during its preparation, Johnson said.

Large bodies of evidence support the association between certain compounds in processed meat and cancer, added Ulrike Peters, PhD, MPH, professor and associate director of the Public Health Sciences Division at the Fred Hutchinson Cancer Center in Seattle.

These compounds include:

• Heterocyclic amines: Prevalent in charred and well-done meat, these chemicals are created from the reaction at high temperatures between creatine/creatinine, amino acids, and sugars.
• Nitrates/nitrites: Widely used in the curing of meat (eg, sausages, ham, bacon) to give products their pink coloring and savory flavor, these inorganic compounds bind with amines to produce N-nitrosamines, among the most potent genotoxic carcinogens.
• Polycyclic aromatic hydrocarbons: Generated during high-temperature cooking and smoking, these compounds can induce DNA damage in the colon.
• Heme iron: This type of iron, abundant in red and processed meats, promotes formation of carcinogenic N-nitroso compounds and oxidative damage to intestinal tissue.

Peters said that the compounds may work synergistically to increase the risk for CRC through various mechanisms, including DNA damage, inflammation, and altered gut microbiota.

While it would be useful to study whether the different meat-processing methods — for example, smoking vs salting — affect CRC risk differently, “practically, this is difficult because there’s so much overlap,” Liang noted.

 

Risk Mitigation

Lifestyle factors likely play a crucial role in the risk for CRC. For example, a study of European migrants to Australia found that those from countries with lower CRC incidences tended to develop a higher risk for CRC the longer they resided in Australia due to the dietary change.

Understanding how to mitigate these risk factors is becoming increasingly important with the rates of early-onset CRC projected to double by 2030 in the United States, a trend that is also being observed globally.

“With early-onset CRC, it’s becoming quite clear that there’s no single risk factor that’s driving this increase,” Liang said. “We need to look at the risk factors that we know cause CRC in older adults and see which have become more common over time.”

The consumption of processed meats is one such factor that’s been implicated, particularly for early-onset CRC. The average global consumption of all types of meat per capita has increased significantly over the last 50 years. A 2022 report estimated that global mean processed meat consumption was 17 g/d, with significantly higher rates in high-income regions. This number is expected to rise, with the global processed meat market projected to grow from $318 billion in 2023 to $429 billion by 2029. Given this, the importance of counseling patients to reduce their meat intake is further underscored.

Another strategy for mitigating the risks around processed meat is specifically identifying those patients who may be most vulnerable.

In 2024, Peters and colleagues published findings from their genome-wide gene-environment interaction analysis comparing a large population with CRC and healthy control individuals. The research identified two novel biomarkers that support the role of red and processed meat with an increased risk for CRC and may explain the higher risk in certain population subgroups. They are working on genetic risk prediction models that will incorporate these genetic markers but must first ensure robust validation through larger studies.

“This approach aligns with precision medicine principles, allowing for more personalized prevention strategies, though we’re not quite there yet in terms of clinical application,” Peters said.

Another knowledge gap that future research efforts could address is how dietary factors influence survival outcomes after a diagnosis of CRC.

“The existing guidelines primarily focus on cancer prevention, with strong evidence linking processed meat consumption to increased CRC risk. However, the impact of dietary choices on survival after CRC diagnosis remains poorly understood,” Peters said. “This distinction between prevention and survival is crucial, as biological mechanisms and optimal dietary interventions may differ significantly between these two contexts.”

Well-designed studies investigating the relationship between dietary patterns and CRC survival outcomes would enable the development of evidence-based nutritional recommendations specifically tailored for CRC survivors, Peters said. In addition, she called for well-designed studies that compare levels of processed meat consumption between cohorts of patients with early-onset CRC and healthy counterparts.

“This would help establish whether there’s a true causal relationship rather than just correlation,” Peters said.

 

Simple Strategies to Dietary Changes

With a 2024 study finding that greater adherence to WCRF/AICR Cancer Prevention Recommendations, including reducing processed meat consumption, was linked to a 14% reduction in CRC risk, physicians should emphasize the benefits of adopting dietary and lifestyle recommendations to patients.

Johnson advised simple strategies to encourage any needed dietary changes.

“Pay attention to what you eat, proportions, and variation of meal menus. Those are good starter points,” he told GI & Hepatology News. “None of these recommendations related to meats should be absolute, but reduction can be the target.”

Liang stressed the importance of repeated, nonjudgmental discussions.

“Research shows that physician recommendation is one of the strongest motivators in preventive health, so even if it doesn’t work the first few times, we have to continue delivering the message that can improve our patients’ health.”

A version of this article appeared on Medscape.com.

Pancreatic cancer remains one of the most challenging cancers to diagnose early, with almost half of patients presenting with metastatic disease. Now, a growing body of evidence indicates that this deadly cancer has been steadily on the rise, particularly in younger individuals who may not even realize they are at risk.

A recent survey, for instance, found that 33% of 1000 respondents younger than 50 years believe that only older adults are at risk for pancreatic cancer, and more than half said they wouldn’t even recognize the early signs and symptoms, which include unexplained weight loss, fatigue, jaundice, abdominal pain that radiates to the back, nausea, and vomiting.

These survey findings allude to a bigger challenge: Identifying the disease remains elusive against a backdrop of these increasing rates and nonspecific risks and symptoms.

Currently, only about 15% of pancreatic cancers are caught at a localized, resectable stage, when 5-year survival rates are highest at 44%. But most are found later, after symptoms arise, and at this point, the 5-year survival odds plummet —16% for regional disease, 3% for distant, and 1% for stage IV.

 

“This disease is too often a silent killer, with no symptoms until it has progressed to less treatable stages,” said survey coauthor Zobeida Cruz-Monserrate, PhD, in the division of gastroenterology, hepatology and nutrition at Ohio State University Medical Center, Columbus.

 

Rising Rates

Since 2001, rates of pancreatic cancer have steadily increased by about 1% annually, and this increase appears greater among younger individuals, especially women.

A recent study in Gastroenterology, for instance, found that, while overall rates of pancreatic cancer among people aged 15-34 years remained low (0.3% in women and 0.2% in men) between 2001 and 2018, the average annual percent change in this age group was considerably higher than that for older individuals — 6.45% for women and 2.97% for men compared with 1.11% for women aged 55 years and 1.17% for men aged 55 years. Another recent analysis, published in Annals of Internal Medicine, reported similar increased rates in men and women aged 15-39 years between 2011 and 2019.

Although more than 90% of cases do occur in those 55 years or older, “we’re now seeing this disease in people who are in their 40s much more regularly,” Cruz-Monserrate said. “This is a concerning trend — and more research is needed to learn why.”

But it’s early days. Studies so far indicate that early onset pancreatic cancer tends to be even more aggressive, but the “underlying reason is not yet clear,” researcher wrote in a 2025 review.

Some evidence indicates younger individuals may have distinct molecular characteristics, whereas other research shows younger and older patients have similar genetic profiles. Younger patients may also be more likely to smoke, drink more, and delay seeking medical attention as well as experience delays in being diagnosed by physicians, the authors explained.

 

Catching It Early

Given the rising rates, early detection is especially important.

There are some known genetic and medical risk factors for pancreatic cancer. About 10% of these cancers are linked to heredity risk or genetic markers, including BRCA1 and BRCA2 or Lynch syndrome. People with chronic pancreatitis, type 2 diabetes, obesity, or with a family history of pancreatic cancer face an elevated risk.

Lifestyle factors can play a role as well. Alcohol consumption, a poor diet that includes red or processed meat, and smoking increase people’s risk for pancreatic cancer. In fact, smoking leads to a twofold higher risk, compared with not smoking.

 

However, uncovering pancreatic cancer from these factors alone can be like “finding a needle in a haystack,” said Srinivas Gaddam, MD, head of the pancreatic cancer screening and early detection program at Cedars-Sinai Medical Center in Los Angeles.

One strategy to help detect the disease earlier would be to screen more.

The latest guidance from the American Cancer Society suggests that people with a genetic predisposition or a family history of pancreatic cancer could benefit from annual surveillance with endoscopic ultrasound or MRI.

But the US Preventive Services Task Force currently recommends against routine screening of average-risk asymptomatic adults (JAMA. 2019;322[5]:438-444). The task force found no evidence that screening for pancreatic cancer improves disease-specific morbidity or mortality or all-cause mortality.

“The absolute incidence in younger people is far too small to make screening beneficial,” explained The Lancet Gastroenterology & Hepatology editors in a 2023 editorial.

In fact, more screening could lead to overdiagnosis, a concern reinforced by the recent study in Annals of Internal Medicine. That analysis found that much of the observed increase in early-onset pancreatic cancer stemmed from the detection of more small, early-stage endocrine cancer, rather than pancreatic adenocarcinoma, whereas mortality from the disease remained stable over the study period.

Recent findings do “suggest the potential for overdiagnosis and overtreatment, particularly in cases of indolent pancreatic neuroendocrine tumors,” Gaddam said.

Gaddam has observed an increase in both adenocarcinoma and neuroendocrine tumors in the clinic and in his research, especially in women younger than 50 years, but he noted these early onset diagnoses do remain rare.

 

Staying Vigilant

As the understanding of pancreatic cancer risks and symptoms evolves, ensuring that patients, especially younger individuals, recognize the warning signs, without causing alarm, remains a challenge.

The disease “presents more advanced in younger patients, but symptoms are so nonspecific,” said Randall Brand, MD, AGAF, director of the gastrointestinal malignancy early detection, diagnosis, and prevention program at the University of Pittsburgh Medical Center, Pennsylvania. Given that, “I am not sure how to best highlight a communication approach that would not cause undue stress to the patient and our healthcare resources.”

Gaddam agreed that it’s tough to pinpoint or communicate straightforward risks or symptoms to the general public without potentially leading to unnecessary screening.

At a minimum, however, clinicians can share more general risk-mitigating strategies with their patients.

Communicating such strategies may be especially important for younger patients, given that the recent survey found almost 40% of younger adults believe there’s nothing they can do to change their risk for pancreatic cancer.

However, Cruz-Monserrate explained, adults of all ages can lower their risks through regular exercise, limited alcohol and tobacco use, and a healthy diet with less red meat or processed meat.

Ultimately, for clinicians, given how difficult it is now to identify pancreatic cancer early, we have to “follow their good clinical judgment when alarming features, such as weight loss or nuances of pancreatic pain arise, and then get good imaging,” Gaddam said.

Cruz-Monserrate, Brand, and Gaddam reported no relevant disclosures.

A version of this article appeared on Medscape.com.

Pancreatic cancer remains one of the most challenging cancers to diagnose early, with almost half of patients presenting with metastatic disease. Now, a growing body of evidence indicates that this deadly cancer has been steadily on the rise, particularly in younger individuals who may not even realize they are at risk.

A recent survey, for instance, found that 33% of 1000 respondents younger than 50 years believe that only older adults are at risk for pancreatic cancer, and more than half said they wouldn’t even recognize the early signs and symptoms, which include unexplained weight loss, fatigue, jaundice, abdominal pain that radiates to the back, nausea, and vomiting.

These survey findings allude to a bigger challenge: Identifying the disease remains elusive against a backdrop of these increasing rates and nonspecific risks and symptoms.

Currently, only about 15% of pancreatic cancers are caught at a localized, resectable stage, when 5-year survival rates are highest at 44%. But most are found later, after symptoms arise, and at this point, the 5-year survival odds plummet —16% for regional disease, 3% for distant, and 1% for stage IV.

 

“This disease is too often a silent killer, with no symptoms until it has progressed to less treatable stages,” said survey coauthor Zobeida Cruz-Monserrate, PhD, in the division of gastroenterology, hepatology and nutrition at Ohio State University Medical Center, Columbus.

 

Rising Rates

Since 2001, rates of pancreatic cancer have steadily increased by about 1% annually, and this increase appears greater among younger individuals, especially women.

A recent study in Gastroenterology, for instance, found that, while overall rates of pancreatic cancer among people aged 15-34 years remained low (0.3% in women and 0.2% in men) between 2001 and 2018, the average annual percent change in this age group was considerably higher than that for older individuals — 6.45% for women and 2.97% for men compared with 1.11% for women aged 55 years and 1.17% for men aged 55 years. Another recent analysis, published in Annals of Internal Medicine, reported similar increased rates in men and women aged 15-39 years between 2011 and 2019.

Although more than 90% of cases do occur in those 55 years or older, “we’re now seeing this disease in people who are in their 40s much more regularly,” Cruz-Monserrate said. “This is a concerning trend — and more research is needed to learn why.”

But it’s early days. Studies so far indicate that early onset pancreatic cancer tends to be even more aggressive, but the “underlying reason is not yet clear,” researcher wrote in a 2025 review.

Some evidence indicates younger individuals may have distinct molecular characteristics, whereas other research shows younger and older patients have similar genetic profiles. Younger patients may also be more likely to smoke, drink more, and delay seeking medical attention as well as experience delays in being diagnosed by physicians, the authors explained.

 

Catching It Early

Given the rising rates, early detection is especially important.

There are some known genetic and medical risk factors for pancreatic cancer. About 10% of these cancers are linked to heredity risk or genetic markers, including BRCA1 and BRCA2 or Lynch syndrome. People with chronic pancreatitis, type 2 diabetes, obesity, or with a family history of pancreatic cancer face an elevated risk.

Lifestyle factors can play a role as well. Alcohol consumption, a poor diet that includes red or processed meat, and smoking increase people’s risk for pancreatic cancer. In fact, smoking leads to a twofold higher risk, compared with not smoking.

 

However, uncovering pancreatic cancer from these factors alone can be like “finding a needle in a haystack,” said Srinivas Gaddam, MD, head of the pancreatic cancer screening and early detection program at Cedars-Sinai Medical Center in Los Angeles.

One strategy to help detect the disease earlier would be to screen more.

The latest guidance from the American Cancer Society suggests that people with a genetic predisposition or a family history of pancreatic cancer could benefit from annual surveillance with endoscopic ultrasound or MRI.

But the US Preventive Services Task Force currently recommends against routine screening of average-risk asymptomatic adults (JAMA. 2019;322[5]:438-444). The task force found no evidence that screening for pancreatic cancer improves disease-specific morbidity or mortality or all-cause mortality.

“The absolute incidence in younger people is far too small to make screening beneficial,” explained The Lancet Gastroenterology & Hepatology editors in a 2023 editorial.

In fact, more screening could lead to overdiagnosis, a concern reinforced by the recent study in Annals of Internal Medicine. That analysis found that much of the observed increase in early-onset pancreatic cancer stemmed from the detection of more small, early-stage endocrine cancer, rather than pancreatic adenocarcinoma, whereas mortality from the disease remained stable over the study period.

Recent findings do “suggest the potential for overdiagnosis and overtreatment, particularly in cases of indolent pancreatic neuroendocrine tumors,” Gaddam said.

Gaddam has observed an increase in both adenocarcinoma and neuroendocrine tumors in the clinic and in his research, especially in women younger than 50 years, but he noted these early onset diagnoses do remain rare.

 

Staying Vigilant

As the understanding of pancreatic cancer risks and symptoms evolves, ensuring that patients, especially younger individuals, recognize the warning signs, without causing alarm, remains a challenge.

The disease “presents more advanced in younger patients, but symptoms are so nonspecific,” said Randall Brand, MD, AGAF, director of the gastrointestinal malignancy early detection, diagnosis, and prevention program at the University of Pittsburgh Medical Center, Pennsylvania. Given that, “I am not sure how to best highlight a communication approach that would not cause undue stress to the patient and our healthcare resources.”

Gaddam agreed that it’s tough to pinpoint or communicate straightforward risks or symptoms to the general public without potentially leading to unnecessary screening.

At a minimum, however, clinicians can share more general risk-mitigating strategies with their patients.

Communicating such strategies may be especially important for younger patients, given that the recent survey found almost 40% of younger adults believe there’s nothing they can do to change their risk for pancreatic cancer.

However, Cruz-Monserrate explained, adults of all ages can lower their risks through regular exercise, limited alcohol and tobacco use, and a healthy diet with less red meat or processed meat.

Ultimately, for clinicians, given how difficult it is now to identify pancreatic cancer early, we have to “follow their good clinical judgment when alarming features, such as weight loss or nuances of pancreatic pain arise, and then get good imaging,” Gaddam said.

Cruz-Monserrate, Brand, and Gaddam reported no relevant disclosures.

A version of this article appeared on Medscape.com.

Pancreatic cancer remains one of the most challenging cancers to diagnose early, with almost half of patients presenting with metastatic disease. Now, a growing body of evidence indicates that this deadly cancer has been steadily on the rise, particularly in younger individuals who may not even realize they are at risk.

A recent survey, for instance, found that 33% of 1000 respondents younger than 50 years believe that only older adults are at risk for pancreatic cancer, and more than half said they wouldn’t even recognize the early signs and symptoms, which include unexplained weight loss, fatigue, jaundice, abdominal pain that radiates to the back, nausea, and vomiting.

These survey findings allude to a bigger challenge: Identifying the disease remains elusive against a backdrop of these increasing rates and nonspecific risks and symptoms.

Currently, only about 15% of pancreatic cancers are caught at a localized, resectable stage, when 5-year survival rates are highest at 44%. But most are found later, after symptoms arise, and at this point, the 5-year survival odds plummet —16% for regional disease, 3% for distant, and 1% for stage IV.

 

“This disease is too often a silent killer, with no symptoms until it has progressed to less treatable stages,” said survey coauthor Zobeida Cruz-Monserrate, PhD, in the division of gastroenterology, hepatology and nutrition at Ohio State University Medical Center, Columbus.

 

Rising Rates

Since 2001, rates of pancreatic cancer have steadily increased by about 1% annually, and this increase appears greater among younger individuals, especially women.

A recent study in Gastroenterology, for instance, found that, while overall rates of pancreatic cancer among people aged 15-34 years remained low (0.3% in women and 0.2% in men) between 2001 and 2018, the average annual percent change in this age group was considerably higher than that for older individuals — 6.45% for women and 2.97% for men compared with 1.11% for women aged 55 years and 1.17% for men aged 55 years. Another recent analysis, published in Annals of Internal Medicine, reported similar increased rates in men and women aged 15-39 years between 2011 and 2019.

Although more than 90% of cases do occur in those 55 years or older, “we’re now seeing this disease in people who are in their 40s much more regularly,” Cruz-Monserrate said. “This is a concerning trend — and more research is needed to learn why.”

But it’s early days. Studies so far indicate that early onset pancreatic cancer tends to be even more aggressive, but the “underlying reason is not yet clear,” researcher wrote in a 2025 review.

Some evidence indicates younger individuals may have distinct molecular characteristics, whereas other research shows younger and older patients have similar genetic profiles. Younger patients may also be more likely to smoke, drink more, and delay seeking medical attention as well as experience delays in being diagnosed by physicians, the authors explained.

 

Catching It Early

Given the rising rates, early detection is especially important.

There are some known genetic and medical risk factors for pancreatic cancer. About 10% of these cancers are linked to heredity risk or genetic markers, including BRCA1 and BRCA2 or Lynch syndrome. People with chronic pancreatitis, type 2 diabetes, obesity, or with a family history of pancreatic cancer face an elevated risk.

Lifestyle factors can play a role as well. Alcohol consumption, a poor diet that includes red or processed meat, and smoking increase people’s risk for pancreatic cancer. In fact, smoking leads to a twofold higher risk, compared with not smoking.

 

However, uncovering pancreatic cancer from these factors alone can be like “finding a needle in a haystack,” said Srinivas Gaddam, MD, head of the pancreatic cancer screening and early detection program at Cedars-Sinai Medical Center in Los Angeles.

One strategy to help detect the disease earlier would be to screen more.

The latest guidance from the American Cancer Society suggests that people with a genetic predisposition or a family history of pancreatic cancer could benefit from annual surveillance with endoscopic ultrasound or MRI.

But the US Preventive Services Task Force currently recommends against routine screening of average-risk asymptomatic adults (JAMA. 2019;322[5]:438-444). The task force found no evidence that screening for pancreatic cancer improves disease-specific morbidity or mortality or all-cause mortality.

“The absolute incidence in younger people is far too small to make screening beneficial,” explained The Lancet Gastroenterology & Hepatology editors in a 2023 editorial.

In fact, more screening could lead to overdiagnosis, a concern reinforced by the recent study in Annals of Internal Medicine. That analysis found that much of the observed increase in early-onset pancreatic cancer stemmed from the detection of more small, early-stage endocrine cancer, rather than pancreatic adenocarcinoma, whereas mortality from the disease remained stable over the study period.

Recent findings do “suggest the potential for overdiagnosis and overtreatment, particularly in cases of indolent pancreatic neuroendocrine tumors,” Gaddam said.

Gaddam has observed an increase in both adenocarcinoma and neuroendocrine tumors in the clinic and in his research, especially in women younger than 50 years, but he noted these early onset diagnoses do remain rare.

 

Staying Vigilant

As the understanding of pancreatic cancer risks and symptoms evolves, ensuring that patients, especially younger individuals, recognize the warning signs, without causing alarm, remains a challenge.

The disease “presents more advanced in younger patients, but symptoms are so nonspecific,” said Randall Brand, MD, AGAF, director of the gastrointestinal malignancy early detection, diagnosis, and prevention program at the University of Pittsburgh Medical Center, Pennsylvania. Given that, “I am not sure how to best highlight a communication approach that would not cause undue stress to the patient and our healthcare resources.”

Gaddam agreed that it’s tough to pinpoint or communicate straightforward risks or symptoms to the general public without potentially leading to unnecessary screening.

At a minimum, however, clinicians can share more general risk-mitigating strategies with their patients.

Communicating such strategies may be especially important for younger patients, given that the recent survey found almost 40% of younger adults believe there’s nothing they can do to change their risk for pancreatic cancer.

However, Cruz-Monserrate explained, adults of all ages can lower their risks through regular exercise, limited alcohol and tobacco use, and a healthy diet with less red meat or processed meat.

Ultimately, for clinicians, given how difficult it is now to identify pancreatic cancer early, we have to “follow their good clinical judgment when alarming features, such as weight loss or nuances of pancreatic pain arise, and then get good imaging,” Gaddam said.

Cruz-Monserrate, Brand, and Gaddam reported no relevant disclosures.

A version of this article appeared on Medscape.com.

Dear colleagues,

 

We now have the ability to remove almost any large colon polyp endoscopically using a variety of techniques — from the widely used endoscopic mucosal resection to the increasingly prevalent endoscopic submucosal dissection. Yet, in this new era, are there specific polyps for which we should exercise caution and consult a surgeon first?

In this issue of Perspectives, Dr. Jeffrey Mosko and Dr. Moamen Gabr discuss the importance of careful polyp selection and argue that almost all polyps can be safely removed endoscopically, with low recurrence rates. In contrast, Dr. Ira Leeds from colorectal surgery offers a counterpoint, urging caution when managing polyps in the cecum and rectum while highlighting the role of minimally invasive surgical approaches. We hope these discussions provide valuable insights to support your approach to managing large colorectal polyps, especially in an era of increasing colon cancer screening. 

We also welcome your thoughts on this topic — join the conversation on X at @AGA_GIHN. 

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

Advantages of Endoscopic Resection for Large Colon Polyps

BY MOAMEN GABR, MD, MSC, AND JEFFREY D. MOSKO MD, MSC

General Advantages

Endoscopy has revolutionized the management of large colorectal polyps, offering a minimally invasive alternative to surgical resection. The dawn of endoscopic resection in the late 20th century, particularly the evolution of endoscopic mucosal resection (EMR) in Japan, marked a paradigm shift in the treatment of colonic lesions by enabling the removal of lesions that would otherwise necessitate surgery.

Endoscopic resection of colorectal polyps is generally performed in an outpatient setting, allowing patients to recover at home the same day. This not only minimizes disruption to daily life but also significantly enhances patient satisfaction.

Most procedures are performed under moderate or deep sedation eliminating the need for general anesthesia. This represents a critical benefit, particularly for older or medically frail patients who are at higher risk of anesthesia-related complications.

From an economic perspective, endoscopic resection reduces healthcare costs by eliminating prolonged hospital stays and complex perioperative care. Additionally, preserving the colon’s structure and function avoids long-term consequences such as altered bowel habits or ostomy dependence, common with surgical interventions.

The advantages of endoscopic intervention are clear: safety, cost-effectiveness, organ preservation, and convenience for patients.

 

Lesion Selection

The superiority of endoscopic resection relies on selecting lesions appropriately, specifically those with a low risk of lymph node metastases. This meticulous process should include assessing a lesion’s size, location, morphology, granularity, microvascular and surface pit pattern using a combination of high-definition white light endoscopy, virtual chromoendoscopy and image magnification (when available).

Gross morphologic assessment utilizes the Paris and LST classifications. Combining the Paris classification, lesion granularity and location is both straightforward and revealing. Ulcerated/excavated lesions (0-III) are concerning for deep invasion. Depressed (0-IIc) morphologies are strongly associated with T1 CRC. Nodular lesions (0-Is or IIa + Is) have a higher risk of T1 colorectal cancer (CRC), compared with flat lesions (0-IIa or 0-IIb). Non-granular lesions (0-Is and 0-IIa + Is) have a higher risk of covert cancer. Finally, the rectosigmoid location is associated with an increased risk of T1 CRC (vs. proximal locations).

Endoscopic surface pattern assessment increases one’s diagnostic accuracy. There are three primary endoscopic surface pattern classifications: NBI International Colorectal Endoscopic (NICE), Japanese NBI expert team (JNET), and Kudo pit pattern classifications. Colonic lesions that have a NICE Type 3, JNET 3, or Kudo type Vn pattern should be referred promptly for surgical resection. Lesions with a JNET 2B or Kudo type VI carry a higher risk of superficial T1 CRC but can still be removed endoscopically (see below) in expert centers. All other lesions should undergo endoscopic resection. 

 

Endoscopic Resection Techniques

Endoscopic resection of large colorectal polyps encompasses two primary techniques: EMR and endoscopic submucosal dissection (ESD), each tailored to specific lesion characteristics and operator expertise.

EMR, the technique of choice for the vast majority of lesions, relies on injecting a submucosal cushion to lift the lesion before excision. Recent advances, including enhanced snare designs and underwater EMR, have improved en-bloc resection rates, significantly reducing recurrence and enhancing the efficacy of this technique.

ESD offers unparalleled precision for en-bloc resection of complex lesions, particularly those with fibrosis or high-risk features. Cutting-edge innovations, such as traction devices, have streamlined the procedure, addressing the traditional challenges of ESD. Despite being more time intensive, ESD minimizes recurrence and provides complete histopathological evaluation, critical for the management of malignant or pre-malignant lesions.

For non-lifting polyps, newer techniques such as endoscopic full-thickness resection (eFTR), using tools like the Full-Thickness Resection Device (FTRD), enable resection of up to 2-3 cm of the colonic or rectal wall. This ensures complete removal of any lesion and its underlying tissue, effectively preventing recurrence.

These advancements demonstrate how endoscopy can tackle even the most challenging colorectal polyps, reinforcing its position as the preferred treatment modality.

 

Perceived Limitations 

With ongoing refinement over the last 2 decades, many of the perceived limitations (below) of endoscopic resection have now been overcome.

• Difficult locations/access: Historically lesions at the anorectal junction, ileocecal valve, appendiceal orifice and anastomoses were preferentially sent for surgery. In spite of unique technical challenges at each of these locations, there is now compelling data supporting EMR for these scenarios. We now also have techniques aimed at enabling the resection of lesions with poor access including patient repositioning, distal attachments, variable endoscope diameter/flexibility, traction and overtube devices.
• Recurrence: In the past, recurrence after endoscopic resection of lesions > 20 mm has been reported to be as high as 20%. With our current systematic approach to complete resection, meticulous examination of the post-resection defect for residual polyp tissue, adjunctive techniques to address submucosal fibrosis (hot avulsion, CAST, submucosal release) and thermal ablation to the resection margin (EMR-T), the risk of recurrence for piecemeal resections can be decreased to < 5%. In fact, some groups argue for the en-bloc resection of all large colorectal lesions based on the extremely low (< 1%) recurrence rates and potential for decreased follow-up.
• Post-resection bleeding: Post-resection bleeding is no longer a major limitation of any endoscopic approach because of the combination of improved intra-procedural hemostatic and resection techniques, optimized electrosurgical technology, and enhanced defect closure capabilities and devices (with prophylactic defect closure now supported by randomized control trial level data).
• Perforation: Deep mural injury, once an endoscopists’ worst fear during resection, is no longer a surgical emergency. It can now be predicted, identified (Sydney classification) and successfully managed. In spite of more widespread aggressive resection strategies, the risk of emergency surgery in patients undergoing EMR and even ESD (where the risk of DMI is significantly higher) is extremely low.

Endoscopic resection for large colorectal polyps is effective, available, minimally invasive and organ sparing making it the standard of care for the management of colonic polyps. With ongoing iteration in techniques, more invasive surgical approaches can be avoided in almost all patients with benign and low-risk T1 colorectal cancers.

Dr. Gabr is associate GI division director at the University of Cincinnati, Ohio. Dr. Mosko is based in the division of gastroenterology at St. Michael’s Hospital, Toronto, Ontario, Canada. The authors declare no conflicts of interest.

Blurred Lines: Polyp Needing Surgical versus Endoscopic Excision

BY IRA LEEDS, MD

I am grateful for the invitation to join in discussion with Dr. Gabr and Dr. Mosko on the ever-increasing role of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). However, as a surgeon, I do carry at least mild trepidation entering one of the literary “safe spaces” of my gastroenterology colleagues.

With the increasing evidentiary support of EMR approaches and the increasing experience of those performing ESD, these two techniques are quickly becoming the options of choice. As these practices become ubiquitous, it is important to recognize both their advantages and limitations, compared with available surgical options. The decision to proceed with EMR and ESD is essentially a turning point away from early surgical referral for a complex lesion. In this discussion, I intend to highlight when EMR and ESD have a clear advantage to early surgical referral, why I believe that early surgical referral is still superior to advanced endoscopic techniques in the rectum, and why the approach for right-sided lesions should hinge on careful shared decision-making. 

 

Endoscopic approaches nearly always beat surgical approaches when considering short-term risks. Even in the best surgical series, colorectal surgery typically leads to complications in 10%-15% of patients, 1%-5% being serious. Moreover, transabdominal surgical interventions (ie, colectomy) require considerable recovery involving at least a few days in the inpatient setting and over a month of activity restrictions. Finally, there is a minority of chronically unwell patients who cannot tolerate surgical intervention but may be fortunate enough to have a lesion that with enhanced attention can be endoscopically resectioned. While EMR and ESD also contribute a disproportionate burden of complications to endoscopy practice, overall complication rates are still favorable when compared with surgical resection.

Moreover, the most feared short-term complication of EMR and ESD, perforation, has the added benefit of a “controlled failure” to colectomy. Advanced endoscopic approaches already require a prepared colon, and patients are given strict return instructions. Hence, the yearly handful of postprocedural perforations that I get called upon to assist with typically tolerate a routine surgical exploration, repair or resection, and recover at rates equal to or better than elective colon resections. For these reasons, lesions that can be endoscopically removed within appropriate risk tolerances, can and should be considered for EMR or ESD at time of diagnosis.

There are two clinical scenarios where this consideration for up-front EMR or ESD requires further caution. First, any rectal lesion considered for advanced endoscopic techniques really needs to be done in multidisciplinary conference with a colorectal surgeon. In the modern era of colorectal surgery, surgeons now have numerous approaches to reach the rectum that bridge the gap between traditional endoscopy and transabdominal resection. For many rectal lesions, transanal laparoscopic and robotic approaches offer the opportunity for local excision. The most commonly practiced approach, transanal minimally invasive microsurgery (TAMIS), provides many of the benefits of endoscopy (eg, same-day discharge, no activity restrictions, limited periprocedural physiologic stress, low complication rates) while providing the surgical precision, repair strategies, and specimen orientation of conventional surgery. Anecdotally, the time it takes to do a high-quality TAMIS excision in the rectum can be substantially less than that required for a comparable ESD.

For rectal lesions in particular, specimen quality is paramount for oncologic prognosis. Regardless of any intrinsic favorable histopathology or deft hand of the endoscopist, a TAMIS approach will typically provide for a deeper partial thickness or even full thickness excision. More times each year than I would like, I find myself at a multidisciplinary tumor board discussing an endoscopically removed rectal lesion done in a piecemeal fashion or insufficient deep ESD where appropriate risk stratification is impossible and we end up offering patients a likely overly aggressive proctectomy or a potentially oncologically unsound re-excision. Consideration of EMR/ESD vs TAMIS up front would allow better sorting of which technique is most suited to which lesion and avoid these diagnostic dilemmas that only seem to be more common as EMR and ESD practices proliferate.

For a different set of reasons, an advanced cecal adenoma may also be more suited to upfront surgical considerations. Right colon lesions can be more challenging for surveillance for a host of reasons. Procedurally, right colon lesions are undeniably more difficult. The thin-walled cecum can be unforgiving for repeated polypectomies. Despite it being an uncomfortable subject for colonoscopists, the evidence suggests that getting to the cecum is not consistent or 100% expected. Finally, patients can be unwilling to undergo serial bowel preparation and endoscopic examination. In contrast, a laparoscopic right colectomy avoids these issues while also attributing little additional risk. Laparoscopic right-colon operations have overall complication rates of less than 10% and major complications of less than 1%. Hospital stays for laparoscopic right colectomy are typically 3 days or less. Finally, surgery reduces both the frequency of surveillance, and a shortened colon makes surveillance easier.

Advanced polypectomy techniques broaden our ability to address even difficult lesions under the ideally aligned degree of invasive procedure. However, like any procedure, these techniques have their own advantages and limitations. There will always be a minority of premalignant colon lesions that are best suited to surgery-first approaches to treatment. In my practice, maintaining open lines of communication and regular interaction with my endoscopy colleagues naturally leads to polyps being addressed in their most suitable fashion.

Dr. Leeds is assistant professor of surgery at the Yale School of Medicine and a staff surgeon at the VA Connecticut Healthcare System. He declares no conflicts of interest.

Dear colleagues,

 

We now have the ability to remove almost any large colon polyp endoscopically using a variety of techniques — from the widely used endoscopic mucosal resection to the increasingly prevalent endoscopic submucosal dissection. Yet, in this new era, are there specific polyps for which we should exercise caution and consult a surgeon first?

In this issue of Perspectives, Dr. Jeffrey Mosko and Dr. Moamen Gabr discuss the importance of careful polyp selection and argue that almost all polyps can be safely removed endoscopically, with low recurrence rates. In contrast, Dr. Ira Leeds from colorectal surgery offers a counterpoint, urging caution when managing polyps in the cecum and rectum while highlighting the role of minimally invasive surgical approaches. We hope these discussions provide valuable insights to support your approach to managing large colorectal polyps, especially in an era of increasing colon cancer screening. 

We also welcome your thoughts on this topic — join the conversation on X at @AGA_GIHN. 

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

Advantages of Endoscopic Resection for Large Colon Polyps

BY MOAMEN GABR, MD, MSC, AND JEFFREY D. MOSKO MD, MSC

General Advantages

Endoscopy has revolutionized the management of large colorectal polyps, offering a minimally invasive alternative to surgical resection. The dawn of endoscopic resection in the late 20th century, particularly the evolution of endoscopic mucosal resection (EMR) in Japan, marked a paradigm shift in the treatment of colonic lesions by enabling the removal of lesions that would otherwise necessitate surgery.

Endoscopic resection of colorectal polyps is generally performed in an outpatient setting, allowing patients to recover at home the same day. This not only minimizes disruption to daily life but also significantly enhances patient satisfaction.

Most procedures are performed under moderate or deep sedation eliminating the need for general anesthesia. This represents a critical benefit, particularly for older or medically frail patients who are at higher risk of anesthesia-related complications.

From an economic perspective, endoscopic resection reduces healthcare costs by eliminating prolonged hospital stays and complex perioperative care. Additionally, preserving the colon’s structure and function avoids long-term consequences such as altered bowel habits or ostomy dependence, common with surgical interventions.

The advantages of endoscopic intervention are clear: safety, cost-effectiveness, organ preservation, and convenience for patients.

 

Lesion Selection

The superiority of endoscopic resection relies on selecting lesions appropriately, specifically those with a low risk of lymph node metastases. This meticulous process should include assessing a lesion’s size, location, morphology, granularity, microvascular and surface pit pattern using a combination of high-definition white light endoscopy, virtual chromoendoscopy and image magnification (when available).

Gross morphologic assessment utilizes the Paris and LST classifications. Combining the Paris classification, lesion granularity and location is both straightforward and revealing. Ulcerated/excavated lesions (0-III) are concerning for deep invasion. Depressed (0-IIc) morphologies are strongly associated with T1 CRC. Nodular lesions (0-Is or IIa + Is) have a higher risk of T1 colorectal cancer (CRC), compared with flat lesions (0-IIa or 0-IIb). Non-granular lesions (0-Is and 0-IIa + Is) have a higher risk of covert cancer. Finally, the rectosigmoid location is associated with an increased risk of T1 CRC (vs. proximal locations).

Endoscopic surface pattern assessment increases one’s diagnostic accuracy. There are three primary endoscopic surface pattern classifications: NBI International Colorectal Endoscopic (NICE), Japanese NBI expert team (JNET), and Kudo pit pattern classifications. Colonic lesions that have a NICE Type 3, JNET 3, or Kudo type Vn pattern should be referred promptly for surgical resection. Lesions with a JNET 2B or Kudo type VI carry a higher risk of superficial T1 CRC but can still be removed endoscopically (see below) in expert centers. All other lesions should undergo endoscopic resection. 

 

Endoscopic Resection Techniques

Endoscopic resection of large colorectal polyps encompasses two primary techniques: EMR and endoscopic submucosal dissection (ESD), each tailored to specific lesion characteristics and operator expertise.

EMR, the technique of choice for the vast majority of lesions, relies on injecting a submucosal cushion to lift the lesion before excision. Recent advances, including enhanced snare designs and underwater EMR, have improved en-bloc resection rates, significantly reducing recurrence and enhancing the efficacy of this technique.

ESD offers unparalleled precision for en-bloc resection of complex lesions, particularly those with fibrosis or high-risk features. Cutting-edge innovations, such as traction devices, have streamlined the procedure, addressing the traditional challenges of ESD. Despite being more time intensive, ESD minimizes recurrence and provides complete histopathological evaluation, critical for the management of malignant or pre-malignant lesions.

For non-lifting polyps, newer techniques such as endoscopic full-thickness resection (eFTR), using tools like the Full-Thickness Resection Device (FTRD), enable resection of up to 2-3 cm of the colonic or rectal wall. This ensures complete removal of any lesion and its underlying tissue, effectively preventing recurrence.

These advancements demonstrate how endoscopy can tackle even the most challenging colorectal polyps, reinforcing its position as the preferred treatment modality.

 

Perceived Limitations 

With ongoing refinement over the last 2 decades, many of the perceived limitations (below) of endoscopic resection have now been overcome.

• Difficult locations/access: Historically lesions at the anorectal junction, ileocecal valve, appendiceal orifice and anastomoses were preferentially sent for surgery. In spite of unique technical challenges at each of these locations, there is now compelling data supporting EMR for these scenarios. We now also have techniques aimed at enabling the resection of lesions with poor access including patient repositioning, distal attachments, variable endoscope diameter/flexibility, traction and overtube devices.
• Recurrence: In the past, recurrence after endoscopic resection of lesions > 20 mm has been reported to be as high as 20%. With our current systematic approach to complete resection, meticulous examination of the post-resection defect for residual polyp tissue, adjunctive techniques to address submucosal fibrosis (hot avulsion, CAST, submucosal release) and thermal ablation to the resection margin (EMR-T), the risk of recurrence for piecemeal resections can be decreased to < 5%. In fact, some groups argue for the en-bloc resection of all large colorectal lesions based on the extremely low (< 1%) recurrence rates and potential for decreased follow-up.
• Post-resection bleeding: Post-resection bleeding is no longer a major limitation of any endoscopic approach because of the combination of improved intra-procedural hemostatic and resection techniques, optimized electrosurgical technology, and enhanced defect closure capabilities and devices (with prophylactic defect closure now supported by randomized control trial level data).
• Perforation: Deep mural injury, once an endoscopists’ worst fear during resection, is no longer a surgical emergency. It can now be predicted, identified (Sydney classification) and successfully managed. In spite of more widespread aggressive resection strategies, the risk of emergency surgery in patients undergoing EMR and even ESD (where the risk of DMI is significantly higher) is extremely low.

Endoscopic resection for large colorectal polyps is effective, available, minimally invasive and organ sparing making it the standard of care for the management of colonic polyps. With ongoing iteration in techniques, more invasive surgical approaches can be avoided in almost all patients with benign and low-risk T1 colorectal cancers.

Dr. Gabr is associate GI division director at the University of Cincinnati, Ohio. Dr. Mosko is based in the division of gastroenterology at St. Michael’s Hospital, Toronto, Ontario, Canada. The authors declare no conflicts of interest.

Blurred Lines: Polyp Needing Surgical versus Endoscopic Excision

BY IRA LEEDS, MD

I am grateful for the invitation to join in discussion with Dr. Gabr and Dr. Mosko on the ever-increasing role of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). However, as a surgeon, I do carry at least mild trepidation entering one of the literary “safe spaces” of my gastroenterology colleagues.

With the increasing evidentiary support of EMR approaches and the increasing experience of those performing ESD, these two techniques are quickly becoming the options of choice. As these practices become ubiquitous, it is important to recognize both their advantages and limitations, compared with available surgical options. The decision to proceed with EMR and ESD is essentially a turning point away from early surgical referral for a complex lesion. In this discussion, I intend to highlight when EMR and ESD have a clear advantage to early surgical referral, why I believe that early surgical referral is still superior to advanced endoscopic techniques in the rectum, and why the approach for right-sided lesions should hinge on careful shared decision-making. 

 

Endoscopic approaches nearly always beat surgical approaches when considering short-term risks. Even in the best surgical series, colorectal surgery typically leads to complications in 10%-15% of patients, 1%-5% being serious. Moreover, transabdominal surgical interventions (ie, colectomy) require considerable recovery involving at least a few days in the inpatient setting and over a month of activity restrictions. Finally, there is a minority of chronically unwell patients who cannot tolerate surgical intervention but may be fortunate enough to have a lesion that with enhanced attention can be endoscopically resectioned. While EMR and ESD also contribute a disproportionate burden of complications to endoscopy practice, overall complication rates are still favorable when compared with surgical resection.

Moreover, the most feared short-term complication of EMR and ESD, perforation, has the added benefit of a “controlled failure” to colectomy. Advanced endoscopic approaches already require a prepared colon, and patients are given strict return instructions. Hence, the yearly handful of postprocedural perforations that I get called upon to assist with typically tolerate a routine surgical exploration, repair or resection, and recover at rates equal to or better than elective colon resections. For these reasons, lesions that can be endoscopically removed within appropriate risk tolerances, can and should be considered for EMR or ESD at time of diagnosis.

There are two clinical scenarios where this consideration for up-front EMR or ESD requires further caution. First, any rectal lesion considered for advanced endoscopic techniques really needs to be done in multidisciplinary conference with a colorectal surgeon. In the modern era of colorectal surgery, surgeons now have numerous approaches to reach the rectum that bridge the gap between traditional endoscopy and transabdominal resection. For many rectal lesions, transanal laparoscopic and robotic approaches offer the opportunity for local excision. The most commonly practiced approach, transanal minimally invasive microsurgery (TAMIS), provides many of the benefits of endoscopy (eg, same-day discharge, no activity restrictions, limited periprocedural physiologic stress, low complication rates) while providing the surgical precision, repair strategies, and specimen orientation of conventional surgery. Anecdotally, the time it takes to do a high-quality TAMIS excision in the rectum can be substantially less than that required for a comparable ESD.

For rectal lesions in particular, specimen quality is paramount for oncologic prognosis. Regardless of any intrinsic favorable histopathology or deft hand of the endoscopist, a TAMIS approach will typically provide for a deeper partial thickness or even full thickness excision. More times each year than I would like, I find myself at a multidisciplinary tumor board discussing an endoscopically removed rectal lesion done in a piecemeal fashion or insufficient deep ESD where appropriate risk stratification is impossible and we end up offering patients a likely overly aggressive proctectomy or a potentially oncologically unsound re-excision. Consideration of EMR/ESD vs TAMIS up front would allow better sorting of which technique is most suited to which lesion and avoid these diagnostic dilemmas that only seem to be more common as EMR and ESD practices proliferate.

For a different set of reasons, an advanced cecal adenoma may also be more suited to upfront surgical considerations. Right colon lesions can be more challenging for surveillance for a host of reasons. Procedurally, right colon lesions are undeniably more difficult. The thin-walled cecum can be unforgiving for repeated polypectomies. Despite it being an uncomfortable subject for colonoscopists, the evidence suggests that getting to the cecum is not consistent or 100% expected. Finally, patients can be unwilling to undergo serial bowel preparation and endoscopic examination. In contrast, a laparoscopic right colectomy avoids these issues while also attributing little additional risk. Laparoscopic right-colon operations have overall complication rates of less than 10% and major complications of less than 1%. Hospital stays for laparoscopic right colectomy are typically 3 days or less. Finally, surgery reduces both the frequency of surveillance, and a shortened colon makes surveillance easier.

Advanced polypectomy techniques broaden our ability to address even difficult lesions under the ideally aligned degree of invasive procedure. However, like any procedure, these techniques have their own advantages and limitations. There will always be a minority of premalignant colon lesions that are best suited to surgery-first approaches to treatment. In my practice, maintaining open lines of communication and regular interaction with my endoscopy colleagues naturally leads to polyps being addressed in their most suitable fashion.

Dr. Leeds is assistant professor of surgery at the Yale School of Medicine and a staff surgeon at the VA Connecticut Healthcare System. He declares no conflicts of interest.

Dear colleagues,

 

We now have the ability to remove almost any large colon polyp endoscopically using a variety of techniques — from the widely used endoscopic mucosal resection to the increasingly prevalent endoscopic submucosal dissection. Yet, in this new era, are there specific polyps for which we should exercise caution and consult a surgeon first?

In this issue of Perspectives, Dr. Jeffrey Mosko and Dr. Moamen Gabr discuss the importance of careful polyp selection and argue that almost all polyps can be safely removed endoscopically, with low recurrence rates. In contrast, Dr. Ira Leeds from colorectal surgery offers a counterpoint, urging caution when managing polyps in the cecum and rectum while highlighting the role of minimally invasive surgical approaches. We hope these discussions provide valuable insights to support your approach to managing large colorectal polyps, especially in an era of increasing colon cancer screening. 

We also welcome your thoughts on this topic — join the conversation on X at @AGA_GIHN. 

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

Advantages of Endoscopic Resection for Large Colon Polyps

BY MOAMEN GABR, MD, MSC, AND JEFFREY D. MOSKO MD, MSC

General Advantages

Endoscopy has revolutionized the management of large colorectal polyps, offering a minimally invasive alternative to surgical resection. The dawn of endoscopic resection in the late 20th century, particularly the evolution of endoscopic mucosal resection (EMR) in Japan, marked a paradigm shift in the treatment of colonic lesions by enabling the removal of lesions that would otherwise necessitate surgery.

Endoscopic resection of colorectal polyps is generally performed in an outpatient setting, allowing patients to recover at home the same day. This not only minimizes disruption to daily life but also significantly enhances patient satisfaction.

Most procedures are performed under moderate or deep sedation eliminating the need for general anesthesia. This represents a critical benefit, particularly for older or medically frail patients who are at higher risk of anesthesia-related complications.

From an economic perspective, endoscopic resection reduces healthcare costs by eliminating prolonged hospital stays and complex perioperative care. Additionally, preserving the colon’s structure and function avoids long-term consequences such as altered bowel habits or ostomy dependence, common with surgical interventions.

The advantages of endoscopic intervention are clear: safety, cost-effectiveness, organ preservation, and convenience for patients.

 

Lesion Selection

The superiority of endoscopic resection relies on selecting lesions appropriately, specifically those with a low risk of lymph node metastases. This meticulous process should include assessing a lesion’s size, location, morphology, granularity, microvascular and surface pit pattern using a combination of high-definition white light endoscopy, virtual chromoendoscopy and image magnification (when available).

Gross morphologic assessment utilizes the Paris and LST classifications. Combining the Paris classification, lesion granularity and location is both straightforward and revealing. Ulcerated/excavated lesions (0-III) are concerning for deep invasion. Depressed (0-IIc) morphologies are strongly associated with T1 CRC. Nodular lesions (0-Is or IIa + Is) have a higher risk of T1 colorectal cancer (CRC), compared with flat lesions (0-IIa or 0-IIb). Non-granular lesions (0-Is and 0-IIa + Is) have a higher risk of covert cancer. Finally, the rectosigmoid location is associated with an increased risk of T1 CRC (vs. proximal locations).

Endoscopic surface pattern assessment increases one’s diagnostic accuracy. There are three primary endoscopic surface pattern classifications: NBI International Colorectal Endoscopic (NICE), Japanese NBI expert team (JNET), and Kudo pit pattern classifications. Colonic lesions that have a NICE Type 3, JNET 3, or Kudo type Vn pattern should be referred promptly for surgical resection. Lesions with a JNET 2B or Kudo type VI carry a higher risk of superficial T1 CRC but can still be removed endoscopically (see below) in expert centers. All other lesions should undergo endoscopic resection. 

 

Endoscopic Resection Techniques

Endoscopic resection of large colorectal polyps encompasses two primary techniques: EMR and endoscopic submucosal dissection (ESD), each tailored to specific lesion characteristics and operator expertise.

EMR, the technique of choice for the vast majority of lesions, relies on injecting a submucosal cushion to lift the lesion before excision. Recent advances, including enhanced snare designs and underwater EMR, have improved en-bloc resection rates, significantly reducing recurrence and enhancing the efficacy of this technique.

ESD offers unparalleled precision for en-bloc resection of complex lesions, particularly those with fibrosis or high-risk features. Cutting-edge innovations, such as traction devices, have streamlined the procedure, addressing the traditional challenges of ESD. Despite being more time intensive, ESD minimizes recurrence and provides complete histopathological evaluation, critical for the management of malignant or pre-malignant lesions.

For non-lifting polyps, newer techniques such as endoscopic full-thickness resection (eFTR), using tools like the Full-Thickness Resection Device (FTRD), enable resection of up to 2-3 cm of the colonic or rectal wall. This ensures complete removal of any lesion and its underlying tissue, effectively preventing recurrence.

These advancements demonstrate how endoscopy can tackle even the most challenging colorectal polyps, reinforcing its position as the preferred treatment modality.

 

Perceived Limitations 

With ongoing refinement over the last 2 decades, many of the perceived limitations (below) of endoscopic resection have now been overcome.

• Difficult locations/access: Historically lesions at the anorectal junction, ileocecal valve, appendiceal orifice and anastomoses were preferentially sent for surgery. In spite of unique technical challenges at each of these locations, there is now compelling data supporting EMR for these scenarios. We now also have techniques aimed at enabling the resection of lesions with poor access including patient repositioning, distal attachments, variable endoscope diameter/flexibility, traction and overtube devices.
• Recurrence: In the past, recurrence after endoscopic resection of lesions > 20 mm has been reported to be as high as 20%. With our current systematic approach to complete resection, meticulous examination of the post-resection defect for residual polyp tissue, adjunctive techniques to address submucosal fibrosis (hot avulsion, CAST, submucosal release) and thermal ablation to the resection margin (EMR-T), the risk of recurrence for piecemeal resections can be decreased to < 5%. In fact, some groups argue for the en-bloc resection of all large colorectal lesions based on the extremely low (< 1%) recurrence rates and potential for decreased follow-up.
• Post-resection bleeding: Post-resection bleeding is no longer a major limitation of any endoscopic approach because of the combination of improved intra-procedural hemostatic and resection techniques, optimized electrosurgical technology, and enhanced defect closure capabilities and devices (with prophylactic defect closure now supported by randomized control trial level data).
• Perforation: Deep mural injury, once an endoscopists’ worst fear during resection, is no longer a surgical emergency. It can now be predicted, identified (Sydney classification) and successfully managed. In spite of more widespread aggressive resection strategies, the risk of emergency surgery in patients undergoing EMR and even ESD (where the risk of DMI is significantly higher) is extremely low.

Endoscopic resection for large colorectal polyps is effective, available, minimally invasive and organ sparing making it the standard of care for the management of colonic polyps. With ongoing iteration in techniques, more invasive surgical approaches can be avoided in almost all patients with benign and low-risk T1 colorectal cancers.

Dr. Gabr is associate GI division director at the University of Cincinnati, Ohio. Dr. Mosko is based in the division of gastroenterology at St. Michael’s Hospital, Toronto, Ontario, Canada. The authors declare no conflicts of interest.

Blurred Lines: Polyp Needing Surgical versus Endoscopic Excision

BY IRA LEEDS, MD

I am grateful for the invitation to join in discussion with Dr. Gabr and Dr. Mosko on the ever-increasing role of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). However, as a surgeon, I do carry at least mild trepidation entering one of the literary “safe spaces” of my gastroenterology colleagues.

With the increasing evidentiary support of EMR approaches and the increasing experience of those performing ESD, these two techniques are quickly becoming the options of choice. As these practices become ubiquitous, it is important to recognize both their advantages and limitations, compared with available surgical options. The decision to proceed with EMR and ESD is essentially a turning point away from early surgical referral for a complex lesion. In this discussion, I intend to highlight when EMR and ESD have a clear advantage to early surgical referral, why I believe that early surgical referral is still superior to advanced endoscopic techniques in the rectum, and why the approach for right-sided lesions should hinge on careful shared decision-making. 

 

Endoscopic approaches nearly always beat surgical approaches when considering short-term risks. Even in the best surgical series, colorectal surgery typically leads to complications in 10%-15% of patients, 1%-5% being serious. Moreover, transabdominal surgical interventions (ie, colectomy) require considerable recovery involving at least a few days in the inpatient setting and over a month of activity restrictions. Finally, there is a minority of chronically unwell patients who cannot tolerate surgical intervention but may be fortunate enough to have a lesion that with enhanced attention can be endoscopically resectioned. While EMR and ESD also contribute a disproportionate burden of complications to endoscopy practice, overall complication rates are still favorable when compared with surgical resection.

Moreover, the most feared short-term complication of EMR and ESD, perforation, has the added benefit of a “controlled failure” to colectomy. Advanced endoscopic approaches already require a prepared colon, and patients are given strict return instructions. Hence, the yearly handful of postprocedural perforations that I get called upon to assist with typically tolerate a routine surgical exploration, repair or resection, and recover at rates equal to or better than elective colon resections. For these reasons, lesions that can be endoscopically removed within appropriate risk tolerances, can and should be considered for EMR or ESD at time of diagnosis.

There are two clinical scenarios where this consideration for up-front EMR or ESD requires further caution. First, any rectal lesion considered for advanced endoscopic techniques really needs to be done in multidisciplinary conference with a colorectal surgeon. In the modern era of colorectal surgery, surgeons now have numerous approaches to reach the rectum that bridge the gap between traditional endoscopy and transabdominal resection. For many rectal lesions, transanal laparoscopic and robotic approaches offer the opportunity for local excision. The most commonly practiced approach, transanal minimally invasive microsurgery (TAMIS), provides many of the benefits of endoscopy (eg, same-day discharge, no activity restrictions, limited periprocedural physiologic stress, low complication rates) while providing the surgical precision, repair strategies, and specimen orientation of conventional surgery. Anecdotally, the time it takes to do a high-quality TAMIS excision in the rectum can be substantially less than that required for a comparable ESD.

For rectal lesions in particular, specimen quality is paramount for oncologic prognosis. Regardless of any intrinsic favorable histopathology or deft hand of the endoscopist, a TAMIS approach will typically provide for a deeper partial thickness or even full thickness excision. More times each year than I would like, I find myself at a multidisciplinary tumor board discussing an endoscopically removed rectal lesion done in a piecemeal fashion or insufficient deep ESD where appropriate risk stratification is impossible and we end up offering patients a likely overly aggressive proctectomy or a potentially oncologically unsound re-excision. Consideration of EMR/ESD vs TAMIS up front would allow better sorting of which technique is most suited to which lesion and avoid these diagnostic dilemmas that only seem to be more common as EMR and ESD practices proliferate.

For a different set of reasons, an advanced cecal adenoma may also be more suited to upfront surgical considerations. Right colon lesions can be more challenging for surveillance for a host of reasons. Procedurally, right colon lesions are undeniably more difficult. The thin-walled cecum can be unforgiving for repeated polypectomies. Despite it being an uncomfortable subject for colonoscopists, the evidence suggests that getting to the cecum is not consistent or 100% expected. Finally, patients can be unwilling to undergo serial bowel preparation and endoscopic examination. In contrast, a laparoscopic right colectomy avoids these issues while also attributing little additional risk. Laparoscopic right-colon operations have overall complication rates of less than 10% and major complications of less than 1%. Hospital stays for laparoscopic right colectomy are typically 3 days or less. Finally, surgery reduces both the frequency of surveillance, and a shortened colon makes surveillance easier.

Advanced polypectomy techniques broaden our ability to address even difficult lesions under the ideally aligned degree of invasive procedure. However, like any procedure, these techniques have their own advantages and limitations. There will always be a minority of premalignant colon lesions that are best suited to surgery-first approaches to treatment. In my practice, maintaining open lines of communication and regular interaction with my endoscopy colleagues naturally leads to polyps being addressed in their most suitable fashion.

Dr. Leeds is assistant professor of surgery at the Yale School of Medicine and a staff surgeon at the VA Connecticut Healthcare System. He declares no conflicts of interest.

A young boy with a habit of screaming when he didn’t get his way is among the patients Joannie Yeh, MD, a primary care physician at Nemours Children’s Health in Media, Pennsylvania, has helped in her practice.

Yeh taught the boy to stretch out his hands into the shape of a starfish, then trace around the edges of his fingers while breathing slowly and deeply. His parents later reported that after using the strategy at home, their son was no longer taking his rage out on his younger siblings.

Interventions like breathing exercises are just a few techniques Yeh hopes more primary care clinicians will teach young patients as mental health issues among this population soar to a national state of emergency, major medical groups say. But many children go without treatment because of shortages of mental health clinicians and long wait-lists for appointments.

“Knowledge of different types of interventions allows pediatricians to offer more options to families — more than just medication alone,” Yeh said. “There are some strategies, like cognitive behavioral therapy, that a therapist is equipped to deliver, but we can help explain them or teach simple skills that borrow from principles of higher-level techniques and can help patients and families while they wait to see a therapist.”

The use of techniques that are based on mindfulness, cognitive behavioral therapy, and psychotherapy are especially helpful to pediatricians after a child’s answers on a screener indicate they may be struggling with anxiety, depression, or attention-deficit/hyperactivity disorder (ADHD), said Theresa Nguyen, MD, chair of pediatrics at Greater Baltimore Medical Center, Baltimore.

“It kind of sucks if you come in worried and then your doctor says, ‘Okay, let me send you to a psychiatrist who you can’t see for 6 months; let me send you to a therapist who’s going to take a couple of weeks to get in with,’” Nguyen said.

Yeh said over the past few years she has cared for more youth coming in as follow-ups after an emergency department visit for a mental health episode.

“Oftentimes, this is the first time we become aware that the child is struggling,” Yeh said. “We are seeing issues like intentional medication overdose, referrals after other self-harm actions, or even the discovery of a note indicating the intention to do harm to self.”

Suicide deaths among 10- to 14-year-olds tripled between 2007 and 2018 and held steady through 2021, with rates climbing even among children as young as 8 years, according to a research in JAMA Network Open. Meanwhile, one in five high school students seriously contemplated suicide in 2023 (27% girls, 14% boys).

 

Mental Health Strategies for Kids in Primary Care

While pediatricians cannot replace a mental health professional, they have the unique advantage of maintaining a long-term relationship with patients. Experts said clinicians should take an active role in supporting the mental health of patients through a variety of evidence-based strategies.

Changing Thought Patterns 

Cognitive-behavioral therapy (CBT) involves identifying and challenging automatic negative thoughts, which can affect a child’s emotional state and lead to behaviors like withdrawal or lashing out.

Yeh recommended asking a child about what is bothering them, pointing out unhelpful and negative thoughts, and then offering a different, positive one instead.

She also often draws a picture of the CBT chart, which is a visual representation of how feelings lead to thoughts, and then behaviors.

“I draw this diagram because it helps give the patients a visual understanding of how their feelings and emotions are connected,” Yeh said.

 

Tools to Tolerate Stressful Situations

Simple tools like breathing exercises, body scanning, and physical exercise can help children better tolerate distress.

Pediatricians can also recommend families use guided meditations, which have been shown to lower anxiety and increase positive social behavior, said Mollie Grow, MD, an associate professor of pediatrics at the University of Washington Medicine and Seattle Children’s Hospital, both in Seattle.

But a child might first need to get negative energy out before they can become calm.

“So I’m like, ‘okay, let’s do actual physical exercise. Give me 10 jumping jacks.’ No one’s nervous after those jumping jacks,” Nguyen said. “When you’ve already been triggered, your nerves have gotten going, and you’re starting to spiral, you can’t slow yourself down enough to do a breathing exercise.”

Nguyen also said that cold water quickly calms the nervous system.

“I’ll run cold water in the office and have them put their hand in it until it’s almost frozen,” and the child or teen is able to think more clearly, Nguyen said. “It’s a real physiological response. It works.”

 

The Origin of a Feeling 

Explaining how symptoms of anxiety, depression, or ADHD work can help children and teens better understand that what they are experiencing is normal and better cope, Yeh said.

Clinicians might teach patients about how shallow breathing — a symptom of anxiety — is a result of the brain scanning for danger, and how slowing breathing tricks the brain into feeling safe again.

 

Barriers Abound

The use of these interventions in pediatric settings is not yet widespread, Grow said.

But starting in July 2025, the Accreditation Council for Graduate Medical Education will require pediatric residencies to include 4 weeks of mental health training. How that requirement is fulfilled will be up to residencies, said Brian Alverson, MD, pediatric program director and vice-chair of education at Nemours Children’s Hospital in Wilmington, Delaware.

Even with training, many pediatricians lack the time to address mental health issues during an office visit, said Carlos Lerner, MD, a professor of clinical pediatrics at University of California, Los Angeles Health. And despite low or sometimes no reimbursement for discussing these issues with patients, “the reality is we end up doing it anyway.”

Treating issues like anxiety and depression “is a daily, constant part of the care that I provide for my patients,” said Lerner. “Whether the pandemic or social media exacerbated it, we are absolutely seeing a rise in mental health issues.”

A version of this article first appeared on Medscape.com.

A young boy with a habit of screaming when he didn’t get his way is among the patients Joannie Yeh, MD, a primary care physician at Nemours Children’s Health in Media, Pennsylvania, has helped in her practice.

Yeh taught the boy to stretch out his hands into the shape of a starfish, then trace around the edges of his fingers while breathing slowly and deeply. His parents later reported that after using the strategy at home, their son was no longer taking his rage out on his younger siblings.

Interventions like breathing exercises are just a few techniques Yeh hopes more primary care clinicians will teach young patients as mental health issues among this population soar to a national state of emergency, major medical groups say. But many children go without treatment because of shortages of mental health clinicians and long wait-lists for appointments.

“Knowledge of different types of interventions allows pediatricians to offer more options to families — more than just medication alone,” Yeh said. “There are some strategies, like cognitive behavioral therapy, that a therapist is equipped to deliver, but we can help explain them or teach simple skills that borrow from principles of higher-level techniques and can help patients and families while they wait to see a therapist.”

The use of techniques that are based on mindfulness, cognitive behavioral therapy, and psychotherapy are especially helpful to pediatricians after a child’s answers on a screener indicate they may be struggling with anxiety, depression, or attention-deficit/hyperactivity disorder (ADHD), said Theresa Nguyen, MD, chair of pediatrics at Greater Baltimore Medical Center, Baltimore.

“It kind of sucks if you come in worried and then your doctor says, ‘Okay, let me send you to a psychiatrist who you can’t see for 6 months; let me send you to a therapist who’s going to take a couple of weeks to get in with,’” Nguyen said.

Yeh said over the past few years she has cared for more youth coming in as follow-ups after an emergency department visit for a mental health episode.

“Oftentimes, this is the first time we become aware that the child is struggling,” Yeh said. “We are seeing issues like intentional medication overdose, referrals after other self-harm actions, or even the discovery of a note indicating the intention to do harm to self.”

Suicide deaths among 10- to 14-year-olds tripled between 2007 and 2018 and held steady through 2021, with rates climbing even among children as young as 8 years, according to a research in JAMA Network Open. Meanwhile, one in five high school students seriously contemplated suicide in 2023 (27% girls, 14% boys).

 

Mental Health Strategies for Kids in Primary Care

While pediatricians cannot replace a mental health professional, they have the unique advantage of maintaining a long-term relationship with patients. Experts said clinicians should take an active role in supporting the mental health of patients through a variety of evidence-based strategies.

Changing Thought Patterns 

Cognitive-behavioral therapy (CBT) involves identifying and challenging automatic negative thoughts, which can affect a child’s emotional state and lead to behaviors like withdrawal or lashing out.

Yeh recommended asking a child about what is bothering them, pointing out unhelpful and negative thoughts, and then offering a different, positive one instead.

She also often draws a picture of the CBT chart, which is a visual representation of how feelings lead to thoughts, and then behaviors.

“I draw this diagram because it helps give the patients a visual understanding of how their feelings and emotions are connected,” Yeh said.

 

Tools to Tolerate Stressful Situations

Simple tools like breathing exercises, body scanning, and physical exercise can help children better tolerate distress.

Pediatricians can also recommend families use guided meditations, which have been shown to lower anxiety and increase positive social behavior, said Mollie Grow, MD, an associate professor of pediatrics at the University of Washington Medicine and Seattle Children’s Hospital, both in Seattle.

But a child might first need to get negative energy out before they can become calm.

“So I’m like, ‘okay, let’s do actual physical exercise. Give me 10 jumping jacks.’ No one’s nervous after those jumping jacks,” Nguyen said. “When you’ve already been triggered, your nerves have gotten going, and you’re starting to spiral, you can’t slow yourself down enough to do a breathing exercise.”

Nguyen also said that cold water quickly calms the nervous system.

“I’ll run cold water in the office and have them put their hand in it until it’s almost frozen,” and the child or teen is able to think more clearly, Nguyen said. “It’s a real physiological response. It works.”

 

The Origin of a Feeling 

Explaining how symptoms of anxiety, depression, or ADHD work can help children and teens better understand that what they are experiencing is normal and better cope, Yeh said.

Clinicians might teach patients about how shallow breathing — a symptom of anxiety — is a result of the brain scanning for danger, and how slowing breathing tricks the brain into feeling safe again.

 

Barriers Abound

The use of these interventions in pediatric settings is not yet widespread, Grow said.

But starting in July 2025, the Accreditation Council for Graduate Medical Education will require pediatric residencies to include 4 weeks of mental health training. How that requirement is fulfilled will be up to residencies, said Brian Alverson, MD, pediatric program director and vice-chair of education at Nemours Children’s Hospital in Wilmington, Delaware.

Even with training, many pediatricians lack the time to address mental health issues during an office visit, said Carlos Lerner, MD, a professor of clinical pediatrics at University of California, Los Angeles Health. And despite low or sometimes no reimbursement for discussing these issues with patients, “the reality is we end up doing it anyway.”

Treating issues like anxiety and depression “is a daily, constant part of the care that I provide for my patients,” said Lerner. “Whether the pandemic or social media exacerbated it, we are absolutely seeing a rise in mental health issues.”

A version of this article first appeared on Medscape.com.

A young boy with a habit of screaming when he didn’t get his way is among the patients Joannie Yeh, MD, a primary care physician at Nemours Children’s Health in Media, Pennsylvania, has helped in her practice.

Yeh taught the boy to stretch out his hands into the shape of a starfish, then trace around the edges of his fingers while breathing slowly and deeply. His parents later reported that after using the strategy at home, their son was no longer taking his rage out on his younger siblings.

Interventions like breathing exercises are just a few techniques Yeh hopes more primary care clinicians will teach young patients as mental health issues among this population soar to a national state of emergency, major medical groups say. But many children go without treatment because of shortages of mental health clinicians and long wait-lists for appointments.

“Knowledge of different types of interventions allows pediatricians to offer more options to families — more than just medication alone,” Yeh said. “There are some strategies, like cognitive behavioral therapy, that a therapist is equipped to deliver, but we can help explain them or teach simple skills that borrow from principles of higher-level techniques and can help patients and families while they wait to see a therapist.”

The use of techniques that are based on mindfulness, cognitive behavioral therapy, and psychotherapy are especially helpful to pediatricians after a child’s answers on a screener indicate they may be struggling with anxiety, depression, or attention-deficit/hyperactivity disorder (ADHD), said Theresa Nguyen, MD, chair of pediatrics at Greater Baltimore Medical Center, Baltimore.

“It kind of sucks if you come in worried and then your doctor says, ‘Okay, let me send you to a psychiatrist who you can’t see for 6 months; let me send you to a therapist who’s going to take a couple of weeks to get in with,’” Nguyen said.

Yeh said over the past few years she has cared for more youth coming in as follow-ups after an emergency department visit for a mental health episode.

“Oftentimes, this is the first time we become aware that the child is struggling,” Yeh said. “We are seeing issues like intentional medication overdose, referrals after other self-harm actions, or even the discovery of a note indicating the intention to do harm to self.”

Suicide deaths among 10- to 14-year-olds tripled between 2007 and 2018 and held steady through 2021, with rates climbing even among children as young as 8 years, according to a research in JAMA Network Open. Meanwhile, one in five high school students seriously contemplated suicide in 2023 (27% girls, 14% boys).

 

Mental Health Strategies for Kids in Primary Care

While pediatricians cannot replace a mental health professional, they have the unique advantage of maintaining a long-term relationship with patients. Experts said clinicians should take an active role in supporting the mental health of patients through a variety of evidence-based strategies.

Changing Thought Patterns 

Cognitive-behavioral therapy (CBT) involves identifying and challenging automatic negative thoughts, which can affect a child’s emotional state and lead to behaviors like withdrawal or lashing out.

Yeh recommended asking a child about what is bothering them, pointing out unhelpful and negative thoughts, and then offering a different, positive one instead.

She also often draws a picture of the CBT chart, which is a visual representation of how feelings lead to thoughts, and then behaviors.

“I draw this diagram because it helps give the patients a visual understanding of how their feelings and emotions are connected,” Yeh said.

 

Tools to Tolerate Stressful Situations

Simple tools like breathing exercises, body scanning, and physical exercise can help children better tolerate distress.

Pediatricians can also recommend families use guided meditations, which have been shown to lower anxiety and increase positive social behavior, said Mollie Grow, MD, an associate professor of pediatrics at the University of Washington Medicine and Seattle Children’s Hospital, both in Seattle.

But a child might first need to get negative energy out before they can become calm.

“So I’m like, ‘okay, let’s do actual physical exercise. Give me 10 jumping jacks.’ No one’s nervous after those jumping jacks,” Nguyen said. “When you’ve already been triggered, your nerves have gotten going, and you’re starting to spiral, you can’t slow yourself down enough to do a breathing exercise.”

Nguyen also said that cold water quickly calms the nervous system.

“I’ll run cold water in the office and have them put their hand in it until it’s almost frozen,” and the child or teen is able to think more clearly, Nguyen said. “It’s a real physiological response. It works.”

 

The Origin of a Feeling 

Explaining how symptoms of anxiety, depression, or ADHD work can help children and teens better understand that what they are experiencing is normal and better cope, Yeh said.

Clinicians might teach patients about how shallow breathing — a symptom of anxiety — is a result of the brain scanning for danger, and how slowing breathing tricks the brain into feeling safe again.

 

Barriers Abound

The use of these interventions in pediatric settings is not yet widespread, Grow said.

But starting in July 2025, the Accreditation Council for Graduate Medical Education will require pediatric residencies to include 4 weeks of mental health training. How that requirement is fulfilled will be up to residencies, said Brian Alverson, MD, pediatric program director and vice-chair of education at Nemours Children’s Hospital in Wilmington, Delaware.

Even with training, many pediatricians lack the time to address mental health issues during an office visit, said Carlos Lerner, MD, a professor of clinical pediatrics at University of California, Los Angeles Health. And despite low or sometimes no reimbursement for discussing these issues with patients, “the reality is we end up doing it anyway.”

Treating issues like anxiety and depression “is a daily, constant part of the care that I provide for my patients,” said Lerner. “Whether the pandemic or social media exacerbated it, we are absolutely seeing a rise in mental health issues.”

A version of this article first appeared on Medscape.com.