Letter: Enhancing Risk‐Adapted Colorectal Cancer Screening for People With Diabetes—Authors' Reply

We thank Dr. Liao et al. [1] for their interest in our study, which provided a straightforward and actionable approach for risk-adapted starting ages for colorectal cancer (CRC) screening for people with diabetes or metabolic syndrome [2]. Their comments raise valuable considerations regarding the clinical implementation of personalised screening strategies for this high-risk population. We acknowledge the heterogeneity of diabetes and recognise that patient-level data, especially regarding disease duration or biomarkers like HbA1c, may enhance risk stratification. While the derivation of risk-adapted starting ages in our study aligns with current screening guidelines based on broad, well-established risk factors, such as age and family history, our approach may also provide a practical foundation for future research using more refined, personalised risk-adapted screening strategies, including strategies using biomarkers, machine learning, and artificial intelligence for personalised risk prediction. For example, as previously demonstrated [3, 4], polygenic risk scores, which have been shown to strongly enhance personalised risk prediction, may be particularly informative for risk-adapted screening strategies. Further research should explore their combined use with diabetic-specific parameters and other risk factors [5, 6] for further enhanced personalised screening strategies. Liao et al. raised concerns about potential challenges associated with colonoscopy in individuals with diabetes, particularly regarding bowel preparation and procedural risks. While these factors should be considered, studies have shown that individuals with diabetes have both a higher adenoma detection rate at screening colonoscopy [7] and higher CRC detection in screening with faecal immunochemical tests [8]. Screening modalities for CRC vary globally, with different approaches specific to healthcare system structures. Some countries, such as Denmark and the Netherlands, use stool-based testing as the primary screening modality, followed by colonoscopy for positive cases; others, such as Germany, offer both faecal immunochemical testing and colonoscopy [9]. While our study did not advocate for a specific modality, these variations show the need to align screening initiation with country-specific CRC risk and healthcare systems, irrespective of the modality used. Healthcare providers should consider individuals' risk profiles when determining the most suitable modality [10]. While the points raised by Liao et al. highlighted important areas for further refinement, straightforward risk-adapted screening provides a practical and implementable approach for CRC screening in high-risk individuals with diabetes. Continued research should refine this approach by incorporating risk modelling and biomarkers, while also evaluating cost-effectiveness to ensure its feasibility in clinical and public health settings. Teresa Seum: writing – original draft. Michael Hoffmeister: writing – review and editing. Hermann Brenner: writing – review and editing, supervision. The authors' declarations of personal and financial interests are unchanged from those in the original article [2]. 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.70039. Data sharing is not applicable to this article as no new data were created or analyzed in this study.