Cancer prevention in inflammatory bowel disease depends on the detection of precancerous dysplasia during scheduled screening and surveillance colonoscopy, but the detection and diagnosis of dysplasia remain challenging. In this article, we review the risks of cancer and dysplasia in ulcerative colitis and the current prevention recommendations, and through a sample case, we demonstrate an approach that involves an active partnership between the gastroenterologist or surgeon and pathologist. We address the challenge of management of polypoid lesions and incorporate new information about degree of inflammation as an additional risk of neoplasia in these patients.