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The UK significant polyp and early colorectal cancer (SPECC) program

There is an increased detection of polyps of the colon and rectum due to more public awareness of bowel problems (particularly bowel cancer), and more widespread adoption of colon cancer screening. The fundamental basis of screening is that most colon and rectal cancers originate from a polyp by a process called the polyp – cancer sequence (also known as the adenoma – carcinoma sequence) described by Basil Morson in 1974, a world renowned pathologist in St Mark’s Hospital London [1]. Most polyps are small and can be safely, and fully, removed endoscopically by polypectomy alone and the majority are noninvasive and benign. However, larger polyps are more likely to be malignant and are technically more difficult to remove. Reports suggest that about 5% of colon and rectal polyps are greater than 20mm in size and are complex polyps requiring advanced endoscopic skills such as EMR (endoscopic mucosal resection) or ESD (endoscopic submucosal dissection) to achieve safe and adequate removal [2–4]. It has been established that approximately 10–15% of polyps >20mm in size have a focus or have invasive malignancy. However, generally the malignancy is at the base and superficial biopsies may be misleading with noninvasive low grade or high grade dysplasia in the biopsy fragments. However despite the size and complexity of a polyp, the majority of such polyps are still benign and an alternative treatment to polypectomy, such as bowel resection, may be over-treatment for most patients. Bowel resection has considerable morbidity, and occasional mortality. Rectal resection in particular may result in life-long bowel dysfunction and many patients finish up with a permanent stoma if a lesion is low in the rectum, or if a complication such as anastomotic leakage occurs after a restorative procedure. For this reason careful assessment of the polyp, the patient and the treatment options are crucial. As outlined above, a further key distinction is whether the lesion is in the rectum (and indeed the precise location in the rectum) as both treatment options and functional outcomes vary considerably between treatment for a cancer or significant polyp of the colon or rectum. One major issue has been the difficulty in precisely predicting which lesions are more likely to be malignant based on endoscopic appearance and size alone and the limitations of superficial biopsies. The concept of SPECC