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39 GASTROENTEROLOGY Endoscopic procedures will expand into areas currently managed by both purely pharmacotherapy and surgical approaches. Cur- rent and near-term examples include the development of [peroral endoscopic myotomy], transoral gastroplasty and endoscopic antireflux procedures. It may come to be that the major outgrowth of bariatrics may prove to be in the management of metabolic diseases such as diabetes, ste- atosis and hypertension, and as an adjunct to orthopedic procedures. [Innovative thinking] will come solutions to the problems that plague humankind. David Lieberman, MD, AGA Governing Board Past President; Or- egon Health and Science University (Portland): ere is substantial evidence that CRC screening of average-risk individuals reduces both incidence and mortality of CRC. e current commonly used screening tests, such as fecal immuno- chemical test and colonoscopy, have limitations. A future serum test may incorporate genomics, proteomics or other risk markers that will enable accurate risk stratification: Higher-risk patients will be re- ferred to colonoscopy and low-risk patients for repeat future testing. e future may also bring advances in CRC prevention, either with lifestyle and behavioral change, chemoprevention or alteration of the microbiome. Kevin Liebovich, MD, Illinois Gastroenterology Group (Chicago): Consumerism will be more influential as patients become more in- formed about their care options. Patients will be less reliant on their primary care physician as a referral source and rely more on digital informatics and social media. Cost and insurance benefit transpar- ency will be a strong driver of where patients choose to receive care. Patients will be more adept at online scheduling and want their expe- rience to become more efficient through the utilization of enhanced soware applications. Consolidation will continue among payers and providers, which will continue to impact every aspect of healthcare. However, as healthcare services transition to more risk-based compensation models, larger entities will pursue broader strategic partnerships in an effort to manage risk. is represents an opportunity for large independent physician practices who will be [better] equipped to aggregate data and provide services to a broader market, with lower cost and greater efficiency. Endoscopic procedures will remain the cornerstone of the GI practice. Despite alternative CRC screening options, population demographics and a fixed number of physician trainees will result in continued high demand for endoscopic procedures. GI pro- cedure volumes will continue to migrate away from the hospital outpatient departments to fully integrated and lower-cost ASCs. High demand for GI services may lead to challenges in physician recruitment. Digital health applications and nanotechnologies are progressing at a rapid speed and could enhance the way we treat and manage many GI diseases. e combination of sensor-based technology, via ingestion of nanoparticles for chemotherapeutic drug delivery and monitoring of levels, to genomic evaluation of the individual patient's gut microbiome, will transform GI care as we know it. We will be- come more efficient in diagnosing and treating gastrointestinal and liver disease. Paul Limburg, MD, CMO for screening at Exact Sciences; Mayo Clinic: In the coming decade, healthcare will undergo tremendous change as personalized medicine expands. As a practicing Mayo Clinic gastroenterologist and chief medical officer of Exact Sciences' screening division, I anticipate unparalleled improvements in our ability to address some of the deadliest — yet most preventable — conditions in GI. Advances in our molecular-level understanding of individual patients' symptoms will allow us to define tailored treatment plans, and personalized early cancer detection will become the norm for reducing GI cancer incidence and mortality. Across prevention, diagnostics, and treatment, patients and providers will have enhanced ability to pursue a less invasive, more effective option as their first choice. Like other industries, medicine will continue evolving to meet patients where they are through innovations in at-home testing and noninvasive diagnostics. Combined application of data analytics, AI and augmented reality will play a pivotal role in our ability to identify and address emerging health trends. We will move beyond the outdated "one-size-fits-all" cancer screening paradigm toward individualized risk stratification. For example, based on recently recognized trends in CRC incidence and mortality in younger populations, the American Cancer Society now recommends that average-risk individuals start screening at age 45. 1 Harnessing the vast potential of innovative digital platforms and molecularly-based laboratory technologies will permit rapid, deeper understanding of these disease patterns, leading to effective preventive and therapeu- tic interventions. Unique collaborations are critical to accelerating future health- care breakthroughs. For example, Mayo Clinic and Exact Sciences researchers collaborated to develop a multitarget stool DNA test. Collaborations like this, rooted in rigorous scientific discovery, will lead to revolutionary developments in precision oncology and GI over the next decade. As medical practice and technology evolve, I am confident our mission in GI and at Exact Sciences will remain the same: serving the needs of our patients. Note: Dr. Limburg serves as chief medical officer for screening at Exact Sciences through a contracted services agreement with Mayo Clinic. Dr. Limburg and Mayo Clinic have contractual rights to receive royalties through this agreement. Simon Mathews, MD, AGA Government Affairs Committee Member; Johns Hopkins Medicine (Baltimore): Over the next 10 years, GI will evolve into a field that is increasingly specialized and patient-centered, driven by advances in technology. With respect to increased specialization, the frontier of advanced endoscopy is already pushing the boundaries of what was previously only possible with surgery. is trend will continue with advanced endoscopy providing a more frequent and less invasive alternative to surgical management of disease. is trend is aided by advancements in endoscopic capabilities and other related tools. Ironically, technology will also replace some of our basic diagnostic GI procedures with noninvasive options. Further development of the intelligent capabilities of capsule endoscopy and similar ingestible diagnostics, and the development of novel biomarkers will likely supplant the need to use endoscopy as a primary form of diagnostic assessment. is will have broad implications for CRC screening as well as practice patterns in procedure-heavy practices. Patients will also be able to more easily collect meaningful health data outside the clinical setting — such as in the home through stool- based diagnostics including a more nuanced understanding of the microbiome. As a result, patients and physicians will have a more convenient and comprehensive understanding of GI function in both disease and good health.