In a new editorial in Gastroenterology, Jason A. Dominitz and Douglas J. Robertson examine a central tension in colorectal cancer (CRC) screening: does colonoscopy overdiagnose low-risk lesions, or does FIT risk detecting disease too late?
The discussion is prompted by new analyses from the COLONPREV study, which compared colonoscopy-based screening with biennial fecal immunochemical testing (FIT) in more than 57,000 average-risk individuals. While prior results showed FIT to be noninferior to colonoscopy for CRC mortality, deeper analysis of premalignant lesions complicates that conclusion.
Key insights from COLONPREV:
- Screening colonoscopy detects more advanced premalignant lesions overall than FIT when all screened individuals are considered
- Colonoscopy following an abnormal FIT detects far higher-risk lesions, highlighting FIT’s strength as a risk stratification tool
- Lesions found after abnormal FIT are larger and more advanced, and more often require surgical management—raising concerns about later detection