- Design
- international Delphi consensus, 17 statements across epidemiology, pathogenesis and management
- Population
- 35 international experts from multiple medical disciplines across six world regions
- Primary outcome
- consensus on colorectal cancer risk and its management in MASLD
- Effect
- consensus achieved on all 17 statements, including increased colorectal cancer risk in MASLD and a recommendation for earlier, risk-adapted screening
Thirty-five international experts across Asia, Europe, North America, South America, Oceania and Africa ran a Delphi process on colorectal cancer risk in metabolic dysfunction-associated steatotic liver disease, evaluating 17 statements over epidemiology, pathogenesis and management. Consensus was reached on all 17.
The panel concluded that MASLD is associated with an increased risk of colorectal cancer, that a greater metabolic burden increases that risk further, and that more severe liver disease is associated with worse outcomes in patients who have both conditions. It identified the gut-liver axis and gut dysbiosis as central mechanisms, with possible roles for leptin and adiponectin. On management it endorsed weight loss through lifestyle change, early colorectal cancer screening, bariatric surgery and GLP-1 receptor agonists as candidate risk-reduction strategies, and called for a shift toward earlier, risk-adapted screening.
What this changes in clinic is the framing of a patient who is already in front of you. Patients with MASLD attend repeatedly, are already having liver imaging and metabolic review, and are exactly the group in whom a screening conversation is easy to have and easy to forget. Making fatty liver a prompt to check colorectal screening status costs one question.
Be clear about what this is. A Delphi consensus records what experts agree on; it is not evidence, and it does not establish that earlier screening in MASLD reduces colorectal cancer deaths. The underlying association is observational, so shared risk factors, obesity, diabetes, inactivity and diet, plausibly explain part of it. No screening interval is specified here, and none should be invented. In India, where organised colorectal screening does not exist and colonoscopy is largely opportunistic and self-funded, the practical version of this is opportunistic: ask, and refer the patient who has symptoms, a family history or is over the usual screening age and has never been screened.
- Ask every patient with MASLD whether they are up to date with colorectal cancer screening, and record the answer
- Treat the combination of MASLD with obesity or type 2 diabetes as a reason to raise screening earlier in the conversation
- Do not invent a shortened screening interval: the consensus recommends earlier risk-adapted screening without specifying one
- Say plainly that the link is an association from observational data, not a proven causal chain
- Use the metabolic review you are already doing, weight, glycaemic control and activity, as the intervention with the broadest benefit
The statistics, in plain English
A Delphi study produces agreement, not effect sizes, and unanimity on all 17 statements tells you the panel converged rather than that the underlying data are strong. The evidence beneath it is observational, so the association between MASLD and colorectal cancer cannot be separated cleanly from the obesity, diabetes and inactivity that cause both. That is why the recommendation is to screen earlier rather than to screen differently: earlier screening is low-risk and already indicated in many of these patients, whereas a specific shortened interval would need trial evidence that does not exist.
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