With Colonoscopy Capacity Limited, We Need More Momentum Behind Noninvasive Home-Based Tests, Says Mark Fendrick, MD

Colorectal cancer (CRC) screening is one of the most effective public health strategies for reducing cancer incidence and mortality, Mark Fendrick, MD, stressed in a recent interview with Patient Care. National guidelines, including from the US Preventive Services Task Force (USPSTF), now recommend initiating screening at age 45 for average-risk adults, reflecting rising incidence in younger populations.1,2 However, despite the mortality benefit of early detection, US screening rates remain below national targets, and the pandemic further disrupted colonoscopy capacity and follow-up care,3 according to Fendrick, professor of internal medicine at the School of Medicine and professor of health management and policy in the Schoolf of Public Health at the University of Michigan, in Ann Arbor.

Fendrick also pointed to some bright spots, noting that emerging real-world data suggest important shifts in modality use over the past decade. A large cohort study of insured adults aged 50–75 found that colonoscopy and fecal immunochemical test (FIT) use decreased after the onset of the COVID-19 pandemic, while use of stool DNA testing increased significantly, with variation by sex and socioeconomic status.4 These trends highlight evolving patient preferences and access patterns that are beinning to shape how CRC screening is delivered in practice. Trials and observational research also indicate that offering noninvasive tests such as FIT or multitarget stool DNA options can improve uptake, particularly when paired with outreach and navigation efforts,5,6 both topics that Fendrick touched on in the short video segement above, along with other barriers and opportunities to expand CRC screening.

The following transcript has been lightly edited for style and flow.

Patient Care: If you had to identify the top issues that are preventing the United States from achieving the clinical and economic benefits of colorectal cancer screening, what would those be?

A Mark Fendrick, MD: Thanks so much for having me. I very much enjoy talking about colorectal cancer screening, since it’s one of the most preventable cancers, yet it still accounts for a significant number of cancer deaths in the United States. We’ve had proven screening modalities for decades now, and there are lots of reasons people don’t get screened—whether personal factors, systemic issues, economics, or geography.

One issue that has really come to mind as we try to make a push to reach the millions of people who could benefit, both clinically and economically, from this preventable cancer screening is that with the gold-standard colonoscopy, there just aren’t enough colonoscopists or colonoscopy appointments to go around. While clinicians strongly recommend colonoscopy as the first-line screening test, recent research we’ve done has shown that a minority of people would actually choose colonoscopy if given a choice. Noninvasive screening tests—those you can do at home, stool-based tests like FIT or Cologuard—are often the preferred option.

The issues are paramount and numerous, but I think if we moved to an approach where more initial screening was done with noninvasive testing at home, we could use colonoscopy appointments much more efficiently. Those appointments are fixed and remain backlogged because of the COVID-19 pandemic, as well as the addition of about 20 million Americans who are now recommended for screening based on the recent US Preventive Services Task Force guidelines. Instead of using colonoscopy for initial screening, we could reserve those appointments for higher-risk patients who have already identified an increased likelihood of colorectal cancer by testing positive on stool-based tests.

References

1. Siddique S, Wang R, May FP, et al. Changes in colorectal cancer screening modalities among insured individuals. JAMA Netw Open. 2025;8(10):e2538578. doi:10.1001/jamanetworkopen.2025.38578

2. US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238

3. Makaroff KE, Dominick SA, Fedewa SA, et al. Patient preferences for colorectal cancer screening tests: national survey findings. Prev Med Rep. 2022;27:101799. doi:10.1016/j.pmedr.2022.101799

4. Sabatino SA, White MC, Thompson TD, et al. Use of cancer screening tests, United States, 2023. Prev Chronic Dis. 2025;22:250139. doi:10.5888/pcd22.250139

5. Robertson DJ, Lee JK, Boland CR, et al. Colorectal cancer screening: evidence and guidelines for clinical practice. Gastroenterology. 2024;S0016-5085(24)00164-1. doi:10.1053/j.gastro.2024.01.001

6. McElroy JA, Wan H, Cote ML, et al. Monthly variations in colorectal cancer screening tests in the United States. JMIR Cancer. 2025;11:e64809. doi:10.2196/64809