Teaching Six “blink” features reduces general endoscopist cancer miss rate in image-based assessment of large colorectal polyps

Background and study aims: Accurate cancer detection in large non-pedunculated colorectal polyps (LNPCPs) remains challenging for general endoscopists. We evaluated whether teaching six gross morphological "blink" features could improve accuracy of cancer detection. Methods: This prospective interventional study assessed general endoscopists evaluating 20 LNPCP images (7 with histologically confirmed submucosal invasive cancer including four deep invasions ≥ 1000 µm, 13 benign). Participants assessed images before and after a 2-minute educational video introducing six blink features: spontaneous bleeding, depression, fold deformation, extra redness, ulceration, and chicken-skin mucosa. Primary outcome was change in miss-rate for cancer detection. Generalized linear mixed models accounted for clustering within raters and polyps. Results: The 165 participants included gastroenterology consultants (63.6%), trainees (21.2%), students (1.8%) and colorectal surgeons (13.3%) with median colonoscopy experience of 6.5 years. Post-intervention, the cancer miss rate decreased four-fold from 26.6% (95% confidence interval [CI] 13.4-46.0) to 5.7% (95% CI 2.4-12.8). The improvement was consistent across experience levels. The false alarm rate increased less than two-fold from 25.0% (95% CI 15.1-38.5) to 42.2% (95% CI 27.7-58.2). Multivariable analysis identified spontaneous bleeding (odds ratio [OR] 3.92; 95% CI 3.11-4.96), extra redness (OR 3.66; 95% CI 3.09-4.33), and depression (OR 3.06; 95% CI 2.58-3.64) as independent predictors of cancer among general endoscopists. Mean blink features per polyp were 1.08 (95% CI 0.82-1.40) for benign lesions vs 2.46 (95% CI 1.85-3.12) for cancers. Conclusions: Teaching six blink features to general endoscopists led to a four-times reduction in cancer miss rates in an image-based evaluation. Although specificity decreased, this trade-off favors patient safety because false positives trigger established clinical safeguards whereas missed cancers risk inappropriate endoscopic resection with potentially irreversible consequences. Keywords: Colorectal cancer; Diagnosis and imaging (inc chromoendoscopy, NBI, iSCAN, FICE, CLE...); Endoscopic resection (polypectomy, ESD, EMRc, ...); Endoscopy Lower GI Tract; Polyps / adenomas / ...; Quality and logistical aspects; Training.

Citation

Debels et al (2026). Teaching Six "blink" features reduces general endoscopist cancer miss rate in image-based assessment of large colorectal polyps. Endoscopy international open, 14, a28684812. https://doi.org/10.1055/a-2868-4812

DOI

10.1055/a-2868-4812

URI

https://hdl.handle.net/20.500.14709/1521

License

CC-BY 4.0

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Usage rights

CC-BY 4.0

License

https://creativecommons.org/licenses/by/4.0/