Metabolic Optimization and Risk of Metachronous Advanced Colorectal Neoplasia in Patients With MASLD

Importance: Patients with metabolic dysfunction-associated steatotic liver disease (MASLD) are at increased risk for colorectal neoplasia. It remains unclear whether dynamic improvements in metabolic health can prevent metachronous advanced colorectal neoplasia (ACRN). Objective: To determine whether longitudinal reduction of cardiometabolic risk factors (CMRFs) is associated with a decreased risk of metachronous ACRN among patients with MASLD. Design, Setting, and Participants: This retrospective cohort study of patients who underwent initial and surveillance colonoscopy between January 2009 and December 2021 was conducted at a large tertiary referral center in Taiwan. Data analysis was performed from March 2024 to March 2026. Individuals at least 40 years of age with MASLD who underwent successful removal of at least 1 colorectal adenoma and had a minimum follow-up of 1 year were screened. Patients with a history of colorectal cancer, inflammatory bowel disease, or hereditary polyposis syndromes were excluded. Exposures: Changes in the number of CMRFs (abdominal obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol, hypertension, and impaired fasting glucose) between baseline and surveillance. Participants were grouped by the direction of CMRF count change (reduced, increased, or unchanged). Main Outcomes and Measures: The primary outcome was metachronous ACRN, defined as a metachronous adenoma of at least 10 mm in diameter with villous components or high-grade dysplasia. Results: Of 8258 patients initially screened, 2331 met all criteria and completed the surveillance protocol. Among 2331 included participants (mean [SD] age, 56.7 [8.8] years; 1745 [74.9%] male) with a mean (SD) follow-up 4.0 (2.5) years, the incidence of metachronous ACRN per 1000 patient-years was 16.7 (95% CI, 11.4-23.6) with increased CMRFs, 17.6 (95% CI, 12.9-23.9) with an unchanged number of CMRFs, 11.9 (95% CI, 8.3-16.4) with the reduction of 1 CMRF, and 9.9 (95% CI, 5.8-15.7) with the reduction of at least 2 CMRFs (P = .03). Multivariable analysis showed that CMRF reduction was associated with a significantly lower risk of metachronous ACRN (adjusted hazard ratio [AHR], 0.49 [95% CI, 0.33-0.73]; P < .001). In high-risk subgroups, a decrease in the number of CMRFs was associated with risk reduction (5 CMRFs group: AHR, 0.40 [95% CI, 0.17-0.92]; P = .03; baseline ACRN group: AHR, 0.27 [95% CI, 0.11-0.65]; P = .003). Conclusions and Relevance: In this cohort study of 2331 patients with MASLD, longitudinal CMRF reduction was associated with lower metachronous ACRN risk, suggesting that metabolic optimization should be integrated with endoscopic surveillance as a primary prevention strategy.