Noninvasive CRC Screening Needs More Primary Care Advocates: Thoughts from Mark Fendrick, MD

Colorectal cancer (CRC) screening guidelines emphasize that multiple noninvasive screening options are effective when completed with colonoscopy where indicated, and that test selection should reflect patient preferences, access, and clinical context.¹ Despite this, according to Mark Fendrick, MD, colonoscopy remains the default recommendation in many clinical settings, even as capacity constraints, scheduling delays, and access barriers limit its feasibility as a universal screening strategy.² These challenges are particularly relevant in primary care, where clinicians are tasked with balancing evidence-based recommendations against real-world system limitations, Fendrick said in a recent interview with Patient Care.^©

Fendrick is a widely-recognized researcher in the field of CRC screening feasibility and uptake, and is 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.

National data show that millions of eligible adults remain unscreened for CRC, underscoring the need for approaches that prioritize completion rather than modality.³ Studies and guideline bodies have consistently highlighted the importance of shared decision-making, noting that offering noninvasive screening options increases patient acceptance and may improve overall screening uptake.¹ At the same time, expert groups stress that colonoscopy remains an essential tool—both as a primary screening option for patients who prefer it and as required follow-up after abnormal noninvasive tests.^1,2

"I hope that if shared decision-making is truly embraced, and if primary care clinicians recognize that we simply cannot screen everyone with colonoscopy alone, they will offer noninvasive tests more positively," Fendrick said.

In the short video segement above, Fendrick discussed how clinician advocacy, realistic assessment of system capacity, and a more balanced presentation of screening options may help translate strong evidence into higher real-world screening completion.

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

Patient Care: In your view, how well do you believe frontline clinicians are doing in helping advocate for noninvasive CRC screening tests and in supporting patients as they try to select the right one for them?

Mark Fendrick, MD: I think this is a very interesting issue. As a clinician for more than three decades, I had a strong gut feeling about it, and we’ve now completed an empirical study trying to inform gastroenterologists, primary care clinicians, and patients about the available options for colorectal cancer screening.

It should come as no surprise that clinicians, both primary care clinicians and gastroenterologists, overwhelmingly recommend colonoscopy, given its status as the gold standard. However, there is often a lack of understanding about the [appointment] backlog, appointment delays, and the difficulties patients face just getting in to see a gastroenterologist, let alone scheduling and completing a colonoscopy. As a result, a substantial majority of individuals reported that they would prefer a noninvasive test.

Moving forward, I hope that if shared decision-making is truly embraced, and if primary care clinicians recognize that we simply cannot screen everyone with colonoscopy alone, they will offer noninvasive tests more positively. I want to be clear that we are not suggesting screening colonoscopy should go away. There is capacity for a substantial number of screening colonoscopies, and for patients who want one, that option should remain available.

What we are suggesting is that we use our screening modalities more judiciously. Doing so would allow the benefits of colorectal cancer screening to be realized more broadly and help ensure that the millions of people who remain unscreened actually complete a screening test.

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. 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

3. King SC, King J, Thomas CC, Richardson LC. Baseline estimates of colorectal cancer screening among adults aged 45–75 years—United States, 2022. Prev Chronic Dis. 2025;22:250175. doi:10.5888/pcd22.250175