Colonoscopy or stool test for colorectal cancer screening? - Debate continues

Colorectal cancer (CRC) remains a leading cause of cancer-related morbidity and mortality worldwide. Screening has proven to be a powerful tool in reducing both CRC incidence and mortality. However, the debate over the optimal screening modality-colonoscopy versus stool-based tests-continues to evolve, shaped by emerging evidence, real-world implementation outcomes, and population-specific considerations.
Colonoscopy, often regarded as the gold standard for CRC screening, provides direct visualization of the entire colon and allows for immediate polypectomy. It has a well-established role in both detection and prevention, given its capacity to remove precancerous lesions. Despite its clinical advantages, colonoscopy is resource-intensive, invasive, and associated with procedural risks, including bleeding and perforation. Furthermore, its uptake remains suboptimal in many populations due to logistical, psychological, and financial barriers.
On the other hand, stool-based tests such as the fecal immunochemical test (FIT) offer a non-invasive, cost-effective alternative with high acceptability. FIT-based programs have demonstrated significant population-level reductions in CRC mortality when implemented with high participation and follow-up rates. However, FIT requires regular repeated testing and has limited sensitivity for advanced adenomas, making it less effective as a one-time strategy. In addition, FIT-positive individuals must still undergo colonoscopy for diagnostic confirmation, creating downstream demand for endoscopic services.This lecture will examine the comparative effectiveness of colonoscopy and stool-based screening through the lens of recent randomized trials, cohort studies, and modeling data. Special emphasis will be placed on the balance between test performance (sensitivity, specificity), program adherence, cost-effectiveness, healthcare infrastructure including manpower demand, and the population demographics.
Rather than presenting these two modalities in opposition, this lecture will advocate for a more nuanced, population-centered perspective. A "one-size-fits-all" approach may no longer be sufficient. Instead, tailored strategies that consider individual risk profiles, public preference, healthcare system capacity, and societal values may offer the most pragmatic path forward in reducing the burden of CRC.
The debate continues-but so too does our opportunity to refine and optimize CRC screening for better outcomes.