To provide a comprehensive overview of real-life management of T1 colorectal cancer(CRC) in Italy, through a nationwide survey conducted among CRC screening centres.

Anonymous digital survey sent to all Italian CRC screening centres between May-July 2025, through the National Screening Observatory(ONS)-Italian Group for CRC Screening(GISCOR) network. The questionnaire included 8 items: responder and centre information, multidisciplinary team (MDT), endoscopy, staging, histopathology, treatment and follow-up.

Out of 207 survey links opened,131 questionnaires at least half completed, of which 83 fully completed. The geographical provenience of responses was representative of the screening centres across the country (North 51%, Centre 21%, South-Islands 29%). Participants were mostly >50yo(56%),with>10y of professional experience(74%), mainly gastroenterologists(73%) or surgeons(21%). Most worked in non-academic(77%) level II/III centres(73%), all public or accredited private hospitals, performing 2,000–5,000 screening colonoscopies annually(44%). A MDT for CRC management was present in 91% of centres, with nearly all T1 cases discussed by the MDT. Core members included oncologists, surgeons, gastroenterologists, radiologists, and pathologists, while radiotherapists and palliative care specialists less common. Other specialists—nuclear medicine physicians, psychologists,case manager nurses,geneticists,stomatherapists,anesthetists, nutritionists, internists—were rarely involved. For endoscopic evaluation of lesions, the most used technique was virtual chromoendoscopy(73%) with vital chromoendoscopy nearly abandoned. Lesions were most often described according to Paris and Kudo classification(≈70%) with minimal use of JNET, NICE and Sano(<30%). Responders declared a median of 70% hystologically confirmed T1 already suspected at index endoscopy, but with huge heterogeneity(Q1-Q3 30-80%;range0-100%). Pre-treatment staging was variably performed: always(34%),never(31%),only for rectal lesions(25%), specific cases(10%). Abdominal CT was the main tool for colon lesions, while pelvis MRI for rectal lesions. A post-endoscopic treatment staging was routinely performed, either in all cases(42%) or only with positive margins or high risk hystology(57%). CEA dosage was variably done. A standardized pathology report form for T1 CRC was used in 84% of centres, with key features including lymphovascular invasion (LVI)(95%), grading(92%), deepness of invasion(88%), resection margins(88%), budding(87%), Haggitt classification for peduncolated polyps(71%), with minor presence of MMR(45%) and microRNA(22%) analyses. LVI(92%) and poor differentiation(83%) were most frequently considered high-risk factors. Budding grade 2–3(77%),positive resection margins(80%),deep submucosal invasion(63–73%), and free resection margin<1mm(59%) were variably considered high-risk. In most centres(66%) only one pathologist was responsible for reporting T1CRC cases; when involved two pathologists(34%), both usually of the same institution(89%).T1 colon cancers in most cases were treated locally at first, with secondary surgery only when high risk hystological features were present, often following MDT decision. For T1 rectal cancers, MDT decision had a primary role. For endoscopically removed lesions revealing T1 only after hystological examination, the most used approaches were MDT discussion(41%) or only follow-up if negative margins and high risk hystology absent(32%). EFTR was rarely used to treat the scar of an excised T1 (30%), mostly in case of positive margins at endoscopic excision(56%) or for patients unfit for surgery(28%). Follow-up protocols were highly heterogeneous: for endoscopically treated T1 CRC, follow-up most commonly included endoscopy and clinical evaluation at 12 months, with limited use of imaging. For surgically treated patients, most centres performed comprehensive follow-up at 12 months(endoscopy,abdominal/thoracic imaging,CEA,clinical evaluation), with fewer repeat assessments at 24-36-60 months.

This national survey, like previous  Dutch survey[1], highlights substantial heterogeneity in the management of T1 CRC across Italian screening centres. These findings underscore once again the need for shared recommendations to standardize diagnostic, therapeutic and follow-up pathways to optimize patient outcomes, avoiding overtreatment and malpractice.