Received: 1 February 2021
DOI: 10.1002/ueg2.12076
EDITORIAL
- Accepted: 5 April 2021
AI in colonoscopy and beyond: On the cusp of clinical
implementation?
The ongoing excitement around artificial intelligence (AI) applied to
healthcare stems from the ‘deep learning’ revolution. Deep learning
refers to a subset of AI techniques that use neural networks with
complicated structures to perform tasks, often related to analysis of
images of text.
We have come a long way since the first study applying deep
learning to medicine, which looked at identifying whether skin lesions
are cancerous.1 Two years later, we witnessed the first randomised
control trial (RCT)—this time in gastroenterology. Wang et al. found
that AI‐aided detection of polyps in colonoscopy led to greater
detection of diminutive adenomas.2 Since then, gastroenterology has
continued to lead the field, with five further RCTs—more than all
other specialties combined.
In this issue, Hann et al. outline what these trials have shown and
consider the proximity of clinical application of such algorithms.3
For endoscopic lesions, AI has been explored to detect lesions
(CADe) and characterise them (CADx). As Hann et al. highlight, all
prospective trials have looked at the former, and AI is consistently
found to detect more small polyps.3 Some studies suggest that
AI‐aided techniques could yield a 50% increase in adenoma detection
rate and can reduce colonoscopy‐related costs up to 20%.4 This ap-
pears promising, but further studies are still required to investigate
whether this increased detection translates to reduced rates of
cancer and increased survival.
The need to measure defined clinical endpoints (such as survival
rates), and not just intermediates (such as polyp detection rate), is an
important requirement before the widespread implementation of any
AI algorithm in health care. Such endpoints should include measures
of harm. With colonoscopy, false positives could lead to unnecessary
polypectomies and longer procedures.
These endpoints must be measured in prospective trials.
Research has highlighted promise of AI across gastroenterology, from
analysing liver ultrasound images5 to prognosticating in hepatocel-
lular carcinoma,6 and from personalising pancreatic cancer manage-
ment7 to predicting liver transplantation survival.8 However, the
impact of incorporating such algorithms into clinical workflows has
not yet been robustly assessed.9 Algorithms that perform well in
retrospective studies can have a negative effect when implemented,
as pointed out by the European Society of Gastrointestinal
© 2021 The Authors. United European Gastroenterology Journal published by Wiley Periodicals LLC. on behalf of United European Gastroenterology.
United European Gastroenterol J. 2021;9:525–526.
Endoscopy (ESGE).10 We saw an example of this in CADe for breast
cancer.11 AI for colonoscopy is leading the field in this respect, but
there is still further work to be done.
Another important step is replicability across different settings.
In CADe for colonoscopy, five out of the six RCTs to date were
performed in China, and all were single‐centre studies. To be confi-
dent that findings translate elsewhere, we need large, multi‐centre
prospective trials conducted in different countries. It is feasible
that variations in mucosal appearance, polyp morphology and
endoscopy technology could affect this generalisability. ESGE has
reinforced this sentiment by recommending CADe and CADx only
when ‘reproducible accuracy for colorectal neoplasia is demonstrated
in high‐quality multi‐centre, in vivo clinical studies’.10 Other appli-
cation areas will need the same.
For many groups, the development of AI algorithms for health
care represents a commercial opportunity. Hann et al. outline six
such commercial CADe systems for colonoscopy.3 As well as devel-
oping robust evidence of effectiveness, such algorithms must meet
regulatory approval. The United States Food and Drug Administra-
tion is currently treating AI algorithms as medical devices. However,
these algorithms present additional challenges. AI models can be
updated after deployment in ways that traditional medical devices
cannot. Heterogeneity in data collection methods and clinical work-
flows can also impact performance. The regulatory landscape will
thus need to adapt. Following regulatory approval, commercialisation
would require an appropriate method of reimbursement to be
devised. To our knowledge, the only current precedent is Vizai's
stroke detection algorithm, which was recently granted reimburse-
ment from Medicare in the United States.
The strengths of AI align well with the demands of colonoscopy.
The speed of AI computation allows real‐time input and deep learning
specialises in image analysis. Colonoscopy is doctor‐led, naturally
embedding strong oversight of the algorithm. These factors, amongst
others, have enabled colonoscopy to lead the field regarding evidence
of positive clinical impact. This establishes an important role in laying
the path towards implementation that other AI algorithms may follow.
Future advances will be driven by those with both clinical expertise
-
and technological understanding.12 There is still work to be done, in
particular multi‐centre, international RCTs, tailored regulatory
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