Colorectal cancer (CRC) incidence is rising globally, with a notable shift toward younger-age onset in several regions¹. However, real-world screening data from the Middle East are almost non-existent. There is currently no national colorectal cancer screening program in Saudi Arabia or, more broadly, across most of the Middle East. Our hospital is one of the few centres offering open-access screening colonoscopy for adults aged ≥45 years. This study aims to describe the screening colonoscopy outcomes in asymptomatic adults over four years, quantify adenoma and cancer detection across age groups, and provide foundational data to inform future CRC screening recommendations for Middle Eastern populations.

This was a retrospective cohort analysis conducted at a single tertiary centre in Saudi Arabia. All screening colonoscopies performed between January 2022 and January 2025 were included. Eligible participants were asymptomatic adults undergoing screening, with a routine lower age threshold of 45 years. Data collected included demographics, caecal intubation rates (CIR), Boston Bowel Preparation Scale (BBPS) scores, withdrawal times, polyp and adenoma detection, polyp type, and complications. Colonoscopy quality indicators were evaluated according to ESGE standards³. Descriptive statistics were used for analysis, and outcomes were stratified by age groups: <45, 45–60, and >60 years. Individuals <45 who underwent colonoscopy likely did so for non-documented opportunistic or external indications (e.g., FIT done elsewhere, incidental imaging findings, or family history).

A total of 3,397 screening colonoscopies were included. The mean age was 56.2 years; 61.8% were male. The overall CIR was 98.1%. Bowel preparation quality was high, with a mean BBPS of 7.28 and adequate preparation (BBPS ≥6) in 93.6% of procedures. The mean withdrawal time was 9.5 minutes, with 92% ≥6 minutes. The overall polyp detection rate was 37.9%. Adenoma Detection Rate (ADR) was 15.6%, varying across age groups as follows: <45 years (10.4%), 45–60 years (16.3%), and >60 years (14.9%). Adenomas were identified from age 27 onward. Twenty-two malignant lesions were detected: 1 in <45 years, 14 in 45–60 years, and 7 in >60 years, with the earliest cancer detected at age 43. The overall clinical complication rate was 0.06%, significantly below international benchmarks.

This represents the first large-scale dataset describing screening colonoscopy outcomes from the Middle East. High-quality indicators and very low complication rates demonstrate the feasibility of effective screening delivery in this region. The presence of adenomas and cancers in adults younger than 45 years raises important questions regarding the onset age of colorectal neoplasia in Middle Eastern populations. These findings highlight the need for prospective, population-based studies to determine optimal CRC screening strategies and age thresholds for the region.