Post written by Guo-Chao Zhong, PhD, from the Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.

The fecal immunochemical test and colonoscopy are the most commonly used strategies for colorectal cancer screening worldwide. Colonoscopy is regarded as the most sensitive test for the early detection of colorectal neoplasia. However, such an invasive test raises screening expenditures, increases risks of adverse events, and requires adequate bowel preparation, all of which result in relatively low participation rates in colonoscopy-based screening programs. Compared with colonoscopy, the fecal immunochemical test has poorer 1-time performance for neoplastic detection but higher participation rates. Improved participation of the fecal immunochemical test may offset its relatively poor detection capacity in population screening. However, the most recent guidelines regarding colorectal cancer screening offer conflicting recommendations on these 2 strategies. Specifically, the United States Multi-Society Task Force recommends the fecal immunochemical test or colonoscopy as a first-tier choice for colorectal cancer screening, while the Canadian Task Force on Preventive Health Care supports the fecal immunochemical test but recommends against colonoscopy as a screening test. To our knowledge, the efficacy and cost-effectiveness of fecal immunochemical test screening versus colonoscopy screening for colorectal cancer have not been systematically evaluated in average-risk population.

A meta-analysis of 6 randomized controlled trials showed that the fecal immunochemical test was equivalent to colonoscopy in the detection rate of colorectal cancer. A qualitative synthesis of 17 cost-effectiveness studies showed that annual or biennial fecal immunochemical tests appeared to be very cost-effective or even cost-saving compared with 10-yearly colonoscopy.

However, both efficacy in detecting colorectal neoplasia and cost-effectiveness are only indirect or surrogate measures of colorectal cancer mortality, which is considered the primary outcome in screening trials. Several large-scale randomized controlled trials that are ongoing in the United States and Europe are expected to provide solid data for the efficacy of the fecal immunochemical test and colonoscopy in colorectal cancer screening.

Our study suggests, at least partly, that the fecal immunochemical test is non-inferior to colonoscopy in colorectal cancer screening in an average-risk population, providing supporting evidence for a fecal immunochemical test-based screening program that has been implemented in many countries. Thus, the fecal immunochemical test could be an outstanding alternative for colorectal cancer screening in an average-risk population.

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