Major advances in biomedical optics have increased our ability to detect more colorectal polyps. Increased small (6-9 mm) and diminutive (<6 mm) polyp detection has been reported however the impact of these increases in terms of colorectal cancer prevention is unknown. The same advances that have allowed increased detection have also made in vivo determination of polyp histology possible. As our in-vivo assessment accuracy improves, the need for resection of non neoplastic polyps and pathologic confirmation of low risk adenomas may eventually diminish. The clinical significance of small and diminutive polyps continues to be debated however both retrospective and prospective studies support a low prevalence of advanced pathology in colorectal polyps <10mm in size. Furthermore, natural history studies suggest these polyps exhibit little or slow growth and some may in fact regress over time. Though the overall risk of colonoscopy is low, polypectomy remains the single greatest risk factor, driving interest in methods to avoid polypectomy of non-neoplastic polyps thereby improving safety without reducing cancer prevention effectiveness. A "diagnose and discard" strategy for diminutive adenomas and a "diagnose and leave behind" strategy for diminutive hyperplastic polyps may offer risk and cost reduction without compromising effectiveness but will require the ability to make both accurate high confidence in-vivo polyp assessment and agreement in setting post-polypectomy surveillance intervals. As both our technology and our knowledge increase, we will be better equipped to confidently provide a complete colorectal screening, to manage detected polyps according to their chance for neoplasia, and to provide an accurate assessment of lifetime colorectal cancer risk and need for future surveillance examinations.