Editorial: ‘Risk‐Adapted Starting Ages of Colorectal Cancer Screening for People With Diabetes or Metabolic Syndrome’. Authors' Reply

We thank Dr. Turvill for his interest in our study and his thoughtful comments on the challenges of colorectal cancer (CRC) screening [1, 2]. We fully agree on the importance of encouraging engagement with CRC screening, particularly in societal groups and communities that are struggling. We also agree that simplicity can be a key component contributing to the success of a screening programme. There is compelling evidence from pan-European studies that well-organised screening programmes, in which the use of faecal immunochemical tests (FITs) is made as simple as possible (e.g., by direct mailing of test devices along with user-friendly, easy-to-understand information) may strongly support widespread utilisation and impact of effective CRC screening [3-5]. Major efforts should be made to further optimise such programmes [6, 7]. As Dr. Turvill pointed out, enhancing the use of screening is particularly relevant for those at highest need. While the approach he suggested (i.e., shifting the FIT threshold in favour of communities that are struggling) may appear appealing lowering the FIT threshold in those communities would increase the use of colonoscopy for people at lower rather than higher risk, thereby compromising rather than enhancing the most efficient use of limited resources in such communities (Table 1) [8]. Risk-adapted screening aims for the opposite—the best possible use of limited screening resources among those at highest risk who are most likely to benefit from it. How best to define high-risk groups that might benefit most from more intensive (or earlier commencement of screening) is challenging and subject to ongoing intensive research. The principle of defining earlier starting ages for screening people at increased risk has long been established in clinical practice. For example, those with a family history of CRC are commonly recommended to start screening earlier. However, how much earlier people with a family history and other risk factors are recommended to start screening varies widely, due partly to a lack of robust empirical evidence. In our study, we aimed to provide the best possible empirical evidence on how much earlier people with known diabetes or metabolic syndrome reach the same risk of CRC as people without these conditions. Compared to other intensively investigated candidates for risk stratification and defining risk-adapted screening ages, such as genetic predisposition or lifestyle habits [9, 10], information on a previous diagnosis of diabetes should usually be readily available and known to both the patients and their doctors. Our results may help to translate the knowledge on increased CRC risk among people with diabetes or metabolic syndrome into evidence-based, easily communicable and easily comprehensible implications for risk-adapted CRC screening. Clearly, a history of diabetes is not the only factor to be considered in this context, but also it is an important and readily available one. With the major increase in incidence and prevalence of both diabetes and early-onset CRC in many countries, risk-adapted screening for people with diabetes or metabolic syndrome may make a major contribution to lowering the increasing burden of early-onset CRC. Hermann Brenner: writing – original draft. Teresa Seum: writing – review and editing. Michael Hoffmeister: writing – review and editing. The authors' declarations of personal and financial interests are unchanged from those in the original article [1]. This article is linked to Seum et al papers. To view these articles, visit https://doi.org/10.1111/apt.18435 and https://doi.org/10.1111/apt.70106. Data sharing is not applicable to this article as no new data were created or analyzed in this study.