Teaching Six ‘Blink’ Features Reduces General Endoscopists’ Cancer Miss-Rate in Image-Based Assessment of Large Colorectal Polyps

Background & 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 the accuracy of cancer detection. Methods This prospective interventional study assessed general endoscopists evaluating 20 LNPCP images (7 with histologically-confirmed submucosal invasive cancer including 4 deep invasions ≥ 1000µm, 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 165 participants included gastroenterology consultants (63.6%), trainees (21.2%), students (1.8%) and colorectal surgeons (13.3%) with a median colonoscopy experience of 6.5 years. Post-intervention the cancer miss-rate decreased four-fold from 26.6% (95%CI 13.4–46.0) to 5.7% (95%CI 2.4–12.8). This 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 (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 amongst general endoscopists. Mean Blink features per polyp were 1.08 (95%CI 0.82–1.40) for benign lesions versus 2.46 (95%CI 1.85–3.12) for cancers. Conclusions Teaching six Blink features to general endoscopists led to a 4x reduction in cancer miss-rates in an image-based evaluation. While specificity decreased, this trade-off favors patient safety, as false-positives trigger established clinical safeguards while missed cancers risk inappropriate endoscopic resection with potentially irreversible consequences. Graphical Abstract