Introduction Colonoscopy has become the dominant colorectal cancer (CRC) screening test in the United States, credited with major reductions in CRC incidence and mortality through detection and polypectomy. Yet CRC screening uptake targets remain unmet, alternative tests (especially FIT) have strong evidence, and health systems are increasingly shifting from opportunistic to programmatic screening—raising an uncomfortable but necessary question: should colonoscopy still be promoted as “the best” screening choice?
Introduction
Colonoscopy has become the dominant colorectal cancer (CRC) screening test in the United States, credited with major reductions in CRC incidence and mortality through detection and polypectomy. Yet CRC screening uptake targets remain unmet, alternative tests (especially FIT) have strong evidence, and health systems are increasingly shifting from opportunistic to programmatic screening—raising an uncomfortable but necessary question: should colonoscopy still be promoted as “the best” screening choice?
Summary
This commentary argues that while colonoscopy is the most comprehensive colorectal examination and the “final common pathway” for all screening strategies, it cannot be automatically crowned the best population-wide screening test. The authors highlight that real-world effectiveness is not only about test efficacy, but also about participation, feasibility, adherence over time, and colonoscopy quality (which is operator dependent). In many countries, organised screening programs favour FIT because it is inexpensive, noninvasive, scalable, and can achieve high participation, with colonoscopy reserved for positive tests. The authors emphasise that programmatic stool-based screening—when repeated and paired with reliable follow-up colonoscopy—can deliver prevention benefits comparable to colonoscopy-based strategies.
They point to recent randomised evidence, including COLONPREV, showing that invitations to FIT can achieve CRC incidence and mortality outcomes comparable to invitations to colonoscopy, while requiring fewer colonoscopies due to higher participation and triage. The piece also addresses the financial realities in US gastroenterology and the potential conflict of interest when colonoscopy is preferentially promoted. The conclusion is clear: gastroenterologists should champion CRC screening broadly, simplify choices where needed (often to colonoscopy vs stool-based testing), and align messaging with population-level effectiveness rather than defending colonoscopy as universally “best.”
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