Endoscopic technological innovations for neoplasia detection in organized colorectal cancer screening programs: a systematic review and meta-analysis

Background and Aims: Many endoscopic technological innovations have claimed to increase the adenoma detection rate (ADR), but their role in population-based organized screening programs is debated. Methods: We searched PubMed, EMBASE, and Cochrane Library databases through January 2020 for randomized controlled trials (RCTs) evaluating the role of technological innovations in fecal immunochemical test (FIT)/fecal occult blood test+ subjects. The primary outcome was ADR, and secondary outcomes were advanced ADR, proximal colon ADR, mean adenoma per procedure (MAP), and cancer detection rate. We calculated pooled proportion rates (%) or risk ratio with 95% confidence interval (CI) and degree of heterogeneity (I-2). Results: Overall, 8 high quality RCTs met inclusion criteria with 3645 patients, 1813 (49.7%) in the intervention arm (advanced imaging, 3 studies; mechanical, 5 studies) and 1832 (50.3%) in the standard colonoscopy arm (mean age, 63.6 years). Pooled ADR was 56.5% (95% CI, 49.9%-62.9%) in the intervention arm and 55.9% (95% CI, 48.6%-63%) in the standard colonoscopy arm (relative risk [RR], 1.01; 95% CI, .93-1.10; I-2 = 50.4%). Similarly, no difference was observed for advanced imaging studies (RR, .95; 95% CI, .85-1.07; I-2 = 50.4%) or those with mechanical innovations (RR, 1.04; 95% CI, .92-1.17; I-2 = 69.49%). The pooled MAP was 1.5 in the intervention arm (95% CI, 1.2-1.8) and 1.5 in the standard colonoscopy (95% CI, 1.1-1.8), with no significant difference (unstandardized mean difference, .04; 95% CI, -.13 to .20; I-2 = 53.6%). No difference in advanced ADR, proximal colon ADR, or cancer detection was found. No significant publication bias was found. Conclusions: In our systematic review and meta-analysis, no technological improvement significantly increased detection rate of colorectal neoplasia in FIT+ subjects undergoing high-quality colonoscopy by high detectors, arguing against their implementation in organized programs.