Beyond the scope: integrating digital standardised family history assessment in a modern endoscopy unit – a service improvement project

Objectives Colorectal cancer (CRC) is the third most common cancer in the UK, yet recognition of familial risk and referrals for genetic assessment remains low. This project aimed to (1) develop and implement a streamlined clinical pathway for standardised family history (FH)-based CRC risk assessment and surveillance in patients referred for FH indications and (2) evaluate the feasibility and cost/time efficiency of standardised FH assessment in patients with symptomatic endoscopy to identify individuals with previously unrecognised familial CRC risk. A novel endoscopy genetic counsellor’s (EGC) role was introduced to integrate genetic expertise into routine endoscopy services. Design A service improvement project was implemented at St. George’s Hospital Endoscopy unit. Two cohorts were analysed retrospectively: (A) patients undergoing colonoscopy under FH-based surveillance pathway (n=211) and (B) patients referred under a symptomatic pathway (n=2019). Patients completed a web-based FH questionnaire service (FHQS), reviewed by the EGC, alongside clinical findings. Surveillance recommendations followed current practice guidelines. Results In cohort A, 65.8% (139/211) completed FHQS. Surveillance intervals were adjusted for 80.57% (112/139; p<0.001): 75% (105/139) downgraded and 5% (7/139) upgraded. Surveillance optimisation prevented 347 unwarranted colonoscopies, saving an estimated £288,010. In cohort B, 19.9% (402/2019) responded to FHQS: 39.5% (159/402) classified as ‘clear population risk’. Among 49% (197/402) triggered for three-generation FH assessment, 10.1% (20/197) were identified as moderate risk and 2% (4/197) as high risk. Conclusion Embedding FHQS-EGC within endoscopy enabled standardised FH assessment, improved CRC risk stratification and optimised colonoscopy surveillance. The scalable model supports wider integration of FH-trained staff to improve efficiency and genetic awareness within endoscopy services.