Colonoscopy May be the Gold Standard, But Now It's a CRC Screening Bottleneck, Says Mark Fendrick, MD

Colorectal cancer (CRC) screening has reached a point where the limiting factor is no longer evidence, technology, or even insurance coverage, but alignment—between clinical norms, patient preferences, and system capacity. While colonoscopy remains the most comprehensive single-step screening option, national guidelines make clear that stool-based tests are equally recommended when used appropriately and followed by diagnostic colonoscopy after abnormal results, according to Mark Fendrick, MD, 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. Yet clinical culture has been slower to adapt to the reality that colonoscopy capacity is finite, and that most patients prefer noninvasive screening options.

In a recent interview with Patient Care,^© Fendrick observed: "I think if the clinical community looked more closely at what patients actually want to do regarding screening, and recognized that a minority would choose colonoscopy while a strong majority would choose noninvasive tests, they might ease up on what I sometimes call the 24-karat gold standard of colonoscopy. Stool-based tests, such as Cologuard, are more like 21-karat gold. They are still recommended on the same level playing field by the US Preventive Services Task Force and other guidelines."

This mismatch has practical consequences. Health systems continue to face endoscopy backlogs, Fendrick stressed, even as millions of eligible adults remain unscreened. At the same time, real-world data show that failure to complete follow-up colonoscopy after a positive stool-based test remains a major vulnerability in the screening pathway.¹ As a result, experts have increasingly argued that quality in CRC screening should be defined not by ordering a test, but by completing the process—especially for patients at elevated risk identified through abnormal noninvasive screening.^1,2

In the short video segment above, Fendrick, also a widely recognized researcher on CRC screening modalities and uptake, outlines what he hopes will change in 2026: greater acceptance of patient choice, more realistic use of colonoscopy capacity, and quality metrics that reward completion rather than modality.

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

Patient Care: What would you like to see happen in 2025 that hasn't happened in 2026 in advancing colorectal cancer screening in the US?

Mark Fendrick, MD: I would love to see key opinion leaders—who are largely gastroenterologists, although there are also surgeons and oncologists in this space—recognize that, unlike many areas of clinical medicine where limitations are primarily financial or logistical, colorectal cancer screening is constrained by a colonoscopy backlog and a fixed capacity problem.

I think if the clinical community looked more closely at what patients actually want to do regarding screening, and recognized that a minority would choose colonoscopy while a strong majority would choose noninvasive tests, they might ease up on what I sometimes call the 24-karat gold standard of colonoscopy. Stool-based tests, such as Cologuard, are more like 21-karat gold. They are still recommended on the same level playing field by the US Preventive Services Task Force and other guidelines.

It is also important to understand that for some people this is a two-step process rather than a one-stop shop, as colonoscopy allows for polyp removal or early cancer detection in a single procedure. But that does not mean noninvasive testing should be devalued.

Patient Care: Do you have Any final message for frontline clinicians?

Mark Fendrick, MD: We’ve known for years that colorectal cancer screening is a quality metric that we can achieve, and one where primary care has often led. As we make it easier to choose non-colonoscopic testing—through changes in the electronic medical record, for example—we also need to make it easy, not hard, for patients with a positive test to get scheduled for colonoscopy.

I think that in 2026, and certainly by 2027, the quality metric for colorectal cancer screening will move from simply doing the test to completing the process for those who test positive on noninvasive screening. Screen more people, help them find a screening option that meets their needs—not just yours—and do what you can within your system to ensure that patients with positive results get timely colonoscopy. In my opinion, a patient with a positive test who does not complete follow-up is actually worse off than someone who was never screened, because we’ve identified them as being at much higher risk for polyps and early-stage colorectal cancer.

References

1. Mohl JT, Ciemins EL, Miller-Wilson LA, et al. Rates of follow-up colonoscopy after a positive stool-based screening test result for colorectal cancer among health care organizations in the United States, 2017–2020. JAMA Netw Open. 2023;6(1):e2251384. doi:10.1001/jamanetworkopen.2022.51384

2. Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2017;153(1):307-323. doi:10.1053/j.gastro.2017.05.013