Progress in understanding the biology, natural history, and relationship to colorectal cancer has provided the basis for a rational approach to patients with adenomas. Pathological assessment of polyps is essential for initial management; only adenomas require search for synchronous neoplasia. A finding of a 30%-50% synchronous rate has been observed. After clearing of the colon of all adenomas, follow-up examination will reveal a 30%-50% rate of metachronous adenomas, but usually with unimportant pathology. Patients with no special concerns at initial polypectomy can have surveillance at intervals of approximately 3 years, while those with an incompletely cleared colon, numerous polyps, or large sessile or malignant adenomas need individualized surveillance. Working guidelines can be provided at this time pending observations in ongoing trials. It is expected but not yet proven that control of colonic adenomas will reduce the incidence and mortality from colorectal cancer. Further research into the biology of adenomas and cancer will undoubtedly provide a clear understanding of susceptibility for colorectal adenomas and more selective control strategies.