Colorectal cancer (CRC) screening in the U.S. is no longer limited by evidence, technology, or insurance coverage—but by misalignment between clinical culture, patient preference, and finite system capacity.
While colonoscopy remains the most comprehensive single-step screening tool, national guidelines from the USPSTF and others clearly place stool-based tests on equal footing when used appropriately and followed by diagnostic colonoscopy after abnormal results. Yet, according to Mark Fendrick, MD, clinical norms have been slower to adapt to two realities: colonoscopy capacity is constrained, and most patients prefer noninvasive screening options.
Fendrick argues that gastroenterology has historically treated colonoscopy as the “24-karat gold standard,” even though stool-based tests such as Cologuard—what he calls “21-karat gold”—are guideline-endorsed and more aligned with patient preferences. In practice, this cultural bias has consequences. Endoscopy backlogs persist across health systems, while millions of eligible adults remain unscreened—an outcome driven less by lack of access than by insistence on a modality many patients are reluctant to choose.