Importance: Current post-polypectomy surveillance guidelines prioritize polyp characteristics but insufficiently address demographic disparities and modifiable risk factors, potentially contributing to inequities in colorectal polyp recurrence. Objective: To evaluate the association of demographic factors, obesity, and polyp characteristics with polyp recurrence risk. Design, Setting, and Participants: This retrospective Polypectomy Cohort study included 68,480 adults undergoing their first polypectomy at a tertiary medical center (January 1990-July 2024), with a median follow-up of 4 years. Exposures: Risk factors included race/ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic, Asian/Pacific Islander [API]), polyp onset age (<=50, 51-75, >=76 years), sex, obesity (BMI >30), and polyp characteristics (size, number, location, histology, dysplasia grade). Main Outcomes and Measures: The primary outcome was polyp recurrence-free survival, defined as the time to recurrence following the initial polypectomy. Cox regression analyses assessed associations between recurrence and demographic/clinical factors, adjusting for confounders. Results: Among 68,480 patients (median age 57.8 years; 50.0% female; 86.6% NHW, 10.5% NHB), 19,450 (28.4%) experienced recurrence. Males had higher 5-year recurrence risk (aHR, 1.12 [95% CI, 1.08-1.17]; P = 3.49e-9) than females, with females showing elevated villous histology risk (HR, 2.57 [95% CI, 2.26-2.93] vs males 2.42 [95% CI, 2.09-2.80]). NHB patients had lower 5-year recurrence (24.9% vs 29.1% NHW; aHR, 0.87 [95% CI, 0.81-0.93]; P = 2.92e-5), rising beyond 10 years (aHR, 1.24 [95% CI, 1.06-1.45]; P = 7.59e-3). Age <=50 (aHR, 0.87) and >=76 (aHR, 0.73) was protective vs 51-75. Early-onset polyps were higher in Hispanic (40.9%) and API (32.7%) vs NHW (26.5%). Villous histology (aHR, 2.40 [95% CI, 2.18-2.65]; P = 5.26e-70) and high-grade dysplasia (aHR, 2.91 [95% CI, 2.59-3.27]; P = 7.06e-72) surpassed polyp size (aHR, 1.65 [95% CI, 1.56-1.75]; P = 2.15e-63) as recurrence predictors, while obesity elevated early risk (aHR, 1.14 [95% CI, 1.09-1.18]; P = 5.32e-10). Conclusions and Relevance: Demographic factors, histologic features, and obesity are critical predictors of polyp recurrence. Surveillance guidelines should incorporate histologic risk, obesity management, and equity-focused strategies to optimize outcomes across diverse populations.

The authors have declared no competing interest.

This study did not receive any funding.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This study was reviewed and exempted from human subjects' research by the Institutional Review Board at Vanderbilt University Medical Center (IRB #250158). Patient confidentiality was maintained through data de-identification, and all procedures adhered to relevant ethical standards. Data was stored and analyzed in a secure, encrypted, access-controlled database.

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All data produced in the present study are available upon reasonable request to the authors.