In CRC Screening, Progress Looks More Like Improved Follow-Through vs Next Breaktthrough: Discussion with Mark Fendrick, MD

Current guideline-recommended screening options for colorectal cancer, including colonoscopy and stool-based tests, when followed according to those guidelines, offer substantial mortality, and no new modality introduced in recent years has demonstrated performance superior to existing strategies, 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, observed in a recent interview with Patient Care. Fendrick shifted away from speculating on the "next breakthrough" test in the conversation and instead focused on the imperative to improve real-world implementation of screening programs.

A key limitation of noninvasive screening approaches is the need for timely diagnostic colonoscopy after abnormal results, which occur in approximately 8% to 10% of patients undergoing stool-based testing.¹˒³ Failure to complete this follow-up step substantially reduces the effectiveness of screening and remains a persistent challenge across health systems.³ Studies consistently show that lack of patient understanding, logistical barriers, and confusion about insurance coverage, including whether follow-up colonoscopy is covered without cost sharing, contribute to these gaps.²˒⁴

A breakthrough for Fendrick would be "some type of precommittment device" that would represent the patient's guarantee to the physician that if a stool-based screening test returned a positive result, the patient would follow-up with the colonoscopy. The device would build on his decades-old tactic of having patients sign that committment in their chart. Interventions such as patient navigation, clear pre-test counseling, and explicit expectation-setting around follow-up have emerged as critical tools for improving screening completion. In the short video segment above, Fendrick argues that meaningful progress in CRC screening is more likely to come from addressing these behavioral and system-level barriers than from new testing technologies alone.

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

Patient Care: In terms of research, is there anything in progress or in development now, in 2025, that has the potential to be a breakthrough in the field?

Mark Fendrick, MD: No, I don’t see that happening. I think if we saw something [approved] that was not as invasive as a blood test performing as well as the existing stool-based tests, that would be meaningful, but I’m not sure that even rises to the level of a breakthrough.

For me, the bigger opportunity lies in education and navigation—helping people understand the colorectal cancer screening process. If colonoscopy is not used as the initial screening modality, patients need to understand that for roughly 10% of those who choose a stool-based test, follow-up colonoscopy will be required. A breakthrough, in my view, would be some type of pre-commitment approach. Years ago, I would have patients document in the chart that they did not want colonoscopy initially, but that if a stool-based test came back positive, they were committed to completing one.

There are many reasons people do not follow through. There is still a lack of understanding that follow-up colonoscopy is covered at no cost for most insured patients. In addition, challenges such as transportation, time off work, and caregiving responsibilities for children or parents continue to interfere. These are the issues we need to address to move patients from considering colorectal cancer screening to actually completing it.

References

1. US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238

2. Doubeni CA, Fedewa SA, Levin TR, et al. Modifiable failures in the colorectal cancer screening process and their association with risk of death. Gastroenterology. 2019;156(1):63-74.e6. doi:10.1053/j.gastro.2018.09.040

3. 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

4. Issaka RB, Bell-Brown A, Jewell T, et al. Interventions to increase follow-up of abnormal stool-based colorectal cancer screening tests in safety-net settings: a systematic review. Gastroenterology. 2024;167(5):826-833.e3. doi:10.1053/j.gastro.2024.08.002