Preference for an Alternative to Colonoscopies Growing in the US

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New data from the CONFIRM trial show the noninvasive FIT testing method is increasing in preference over colonoscopy by about 20% annually.

Eligible patients may increasingly prefer an annual fecal immunochemical test (FIT) or fecal occult blood test (FOBT) over a colonoscopy, according to new data.1

In findings from the colorectal cancer screening CONFIRM trial, investigators reported that preference for lesser invasive screening methods has been popularizing among a population of US veterans recruited into the US-based assessment—and that FIT or FOBT have already surpassed colonoscopies as the most popular method of colorectal cancer screening in some regions.

The observation comes at a time when there remains no clear consensus for a single best option to test for colorectal cancer, the second leading cause of cancer death in the US.

The CONFIRM Study Group, led by Alexander Beed, MS, and Tassos Kyriakides, PhD, of the Cooperative Studies Program Coordinating Center at Veterans Affairs (VA) Connecticut Healthcare System, was designed to assess colorectal cancer mortality outcomes associated with FIT or colonoscopy screening among 50,000 adults randomized to either screening method.

Screening for colorectal cancer is “widely recommended” by institutions including the US Preventive Services Task Force (USPSTF) and American Cancer Society, investigators wrote—however, there is no universally endorsed method of screening between colonoscopies and FIT. While colonoscopy is the widely adopted test in the US and provides advantages such as direct evaluation of the colonic mucosa and the ability to remove colorectal polyps, its invasive procedure and association with risk of complications including bleeding and perforation has led to decreased interest from colorectal cancer screening-eligible patients.

The noninvasive FIT method directly measures hemoglobin in stool, become more popular both in the US and globally.

“While tests like FIT are noninvasive, they do have some downsides relative to colonoscopy,” investigators wrote. “The one-time sensitivity of FIT for cancer and cancer precursors14 is significantly less than one-time colonoscopy, although modeling studies have suggested that a program of FIT screening may achieve similar outcomes.”

The CONFIRM study is currently the only large-scale trial comparing the efficacy of colorectal cancer screening methods using mortality as the primary outcome in the US, the team wrote. The latest analysis from the ongoing trial described baseline characteristics of the enrolled patient cohorts and the rationale for ineligibility or nonparticipation from eligible participants.

Beed, Kyriakides and colleagues conducted the cross-sectional analysis with enrolled veteran participants aged 50 – 75 years old with average colorectal cancer risk from 46 Department of VA medical centers across the US from May 2012 – December 2017. Follow-up assessment is planned through 2028; the current data were analyzed between March – December 2022.

Of the 50,126 participants recruited into the trial at the time of analysis, mean age was 59.1 years old; more than 46,000 (93%) were male. Approximately two-thirds (69.1%) of participants identified as White, 24.0% identified as Black, and 11.4% identified as having Hispanic ethnicity.

The team reported that more than 11,000 (18.0%) eligible individuals declined to participate in CONFIRM; nearly half (43.4%) declined due to a stated preference for a specific screening test versus the randomization method. Of that population, 58.5% preferred FOBT or FIT, versus 40.6% who preferred colonoscopy and 1.0% who preferred other screening test such as flexible sigmoidoscopy (P <.001).

When assessing regional trends, investigators observed that participants in the West (65.4%) and Northeast (57.3%) were more likely to prefer FOBT or FIT over colonoscopies. From 2012 – 2017, the preference for FOBT or FIT among participants increased 19% annually (odds ratio [OR], 1.19; 95% CI, 1.14 – 1.25).

The team noted that colorectal cancer screening culture at some participating VA facilities had been dictated by care team preferences for either colonoscopies or FIT.

“The literature examining screening preference, including direct comparison of preference for stool-based testing or colonoscopy, is complex,” they wrote. “Not surprisingly, investigators using analytic hierarchy processes that deconstruct the higher-level decision (ie, which test to choose) from simpler criteria (eg, whether an individual values test accuracy vs convenience) have found colonoscopy to be the preferred test by individuals most valuing accuracy.”

Interestingly, a study presented at the Digestive Disease Week (DDW) 2023 Annual Meeting in Chicago this May showed colorectal cancer screening patients were nearly two-fold more likely to complete a colonoscopy than FIT when given a choice (12.1% vs 5.6%; P <.001).2

“Requiring patients to opt into a screening modality appeared to decrease participation,” the UCLA-based investigators wrote at the time. “These findings provide important insight for future population health strategies for young adults at average-risk for colorectal cancer.”

The CONFIRM study group concluded from their analysis that there has been an increasing preference for noninvasive FIT over time, especially in US region including the West and Northeast.

“Separately, we were able to evaluate reasons why individuals chose not to participate, which helps to elucidate current trends in preferences for noninvasive colorectal cancer screening,” investigators wrote. “Further work to better understand contemporary changes in preference for colorectal cancer screening in the US is warranted.”


  1. Robertson DJ, Dominitz JA, Beed A, Boardman KD, et al. Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial. JAMA Network Open. July 11, 2023. doi:10.1001/jamanetworkopen.2023.21730
  2. Walter K. New Research at DDW Shows Preferences for Colorectal Cancer Screenings. HCPLive. Published May 9, 2023.