Does more surveillance actually mean better cancer prevention? For years, the logic behind post-polypectomy surveillance has been straightforward: patients with “high-risk” adenomas should return for colonoscopy at 3 years because detecting and removing more precursor lesions should reduce colorectal cancer. But the EPoS II randomized trial challenges that assumption. In more than 10,700 patients across 8 European countries with completely removed high-risk adenomas, surveillance beginning at 5 years was noninferior to surveillance beginning at 3 years for colorectal cancer incidence. At 5.5 years: 🔹 Colorectal cancer: 0.77% vs. 0.82% 🔹 Absolute difference: −0.05 percentage points 🔹 And importantly, the 5-year strategy resulted in 4,180 fewer colonoscopies — nearly 50% fewer procedures. The most interesting finding may be what happened to surrogate outcomes. More intensive surveillance detected more advanced adenomas, more adenomas overall, and more serrated polyps. Yet that additional detection did not translate into a meaningful reduction in colorectal cancer incidence over the reported follow-up. That raises a fundamental question in cancer prevention: Are we optimizing what we detect, or what ultimately happens to patients? The editorial by Dr. Shaukat highlights an important implication: the broad category of “high-risk adenoma” may not capture the nuances that actually determine future cancer risk. Future surveillance strategies may need to incorporate: • Quality of the index colonoscopy • Completeness of resection • Adenoma size, number, and histology • Age and comorbidities • More refined predictors of metachronous neoplasia There is an important caveat: these are interim 5-year results, with the primary endpoint planned for 10 years. The noninferiority margin was also narrowly met, and the relatively low number of cancer events limits precision. Still, EPoS II challenges a deeply intuitive principle in preventive medicine: More testing is not automatically better care. The goal of surveillance should ultimately be to reduce the outcomes that matter to patients—not simply to find more lesions. An important rethink of how we define “high risk” and how much surveillance is actually necessary. 🩺 #ColorectalCancer #Gastroenterology #CancerPrevention #Colonoscopy #ClinicalTrials #EvidenceBasedMedicine #Oncology @AasmaShaukatMD @NYULH_DeptofMed @nyugrossman @Perlmutter_CC @NYULH_GastroHep @nyulangone @NEJM nejm.org/doi/full/10.1056/NE…