Is it time to re-assess the practice and practicality of screening colonoscopy?

I performed my first colonoscopy as a board-certified gastroenterologist more than 20 years ago, at a time when the procedure was firmly established as the “gold standard”¹ for colorectal cancer screening. 

Demand was rising rapidly, and in practice I saw firsthand how effective—if invasive—colonoscopy could be in delivering reassurance and preventing cancer. With the benefit of experience, however, it has become clear that a screening strategy centered almost exclusively on colonoscopy is increasingly misaligned with today’s public health realities.

With the benefit of experience, however, it has become clear that a screening strategy centered almost exclusively on colonoscopy is increasingly misaligned with today’s public health realities.

The numbers tell a sobering story. Nearly 60 million adults² in the U.S. are eligible for CRC screening, yet annual colonoscopy capacity is capped at an estimated 15 million procedures.³ Workforce shortages are expected to deepen this gap as the number of gastroenterologists declines.⁴ Without intervention, capacity constraints will continue to delay detection of curable cancers and resectable precancers—placing patients at unnecessary risk.

Simply put, the CRC burden is too large to solve with screening colonoscopy alone. To make meaningful progress, we must reconsider how we deploy the tools available to us.

An inflection point in CRC screening

Several converging forces make this reassessment urgent. The American Cancer Society recently updated its Colorectal Cancer Screening Guideline⁵ to include a wider range of preferred and additional noninvasive options, effectively reducing dependence on colonoscopy for initial screening. At the same time, healthcare workforce pressures, pandemic-driven disruptions, and the broader consumerization of healthcare have changed how patients engage with prevention. The lowered screening age⁶ and rising CRC incidence among adults under 50⁷ further increase the scale and urgency of the challenge.

This moment calls for an adaptive strategy—one that closes the gap between screening eligibility and screening completion. With more options available, the imperative is not just to use the right tools, but to use them for the right patients and purposes. Improving today’s suboptimal status quo will require new screening paradigms that broaden engagement while preserving quality.

Reprioritizing colonoscopy utilization for greater impact

Colonoscopy remains indispensable. It is diagnostic, therapeutic, and sometimes curative. But patient, provider, and system-level barriers limit its effectiveness as a population-wide screening solution. Increasingly, leaders in the GI community acknowledge that screening colonoscopy alone⁸ cannot deliver the reductions in CRC incidence and mortality we aspire to achieve and are looking to noninvasive options as viable—and potentially preferable—alternatives for screening at scale.

Simply put, the CRC burden is too large to solve with screening colonoscopy alone.

High-performing, guideline-preferred noninvasive options—such as next-generation multitarget stool DNA (ng mt-sDNA) tests—make a complementary approach possible. In a recent modeling study⁹ published in Gastro Hep Advances, colleagues and I explored how to optimize the proportional mix of colonoscopy and noninvasive screening modalities to advance CRC screening goals. We modeled what would happen if we redistributed the estimated 15 million available colonoscopies toward follow-up and therapeutic procedures, while increasing utilization of the ng mt-sDNA test for initial screening. The results were striking: CRC detection more than doubled, more cancers were prevented, overall CRC costs declined, and colonoscopy providers benefited from higher-value procedural care.¹⁰

Additional modeling analyses of long-term outcomes reinforce these findings. In data¹¹ presented at Digestive Disease Week 2026 and published in the Journal of Medical Economics, repeated ng mt-sDNA screening outperformed screening colonoscopy across multiple cycles, detecting more precancerous lesions and cancers, reducing mortality, and delivering substantially more life-years gained. 

These outcomes were driven by strong test performance—including the ability to detect early CRC and advanced precancerous lesions¹² at performance levels that may be lost or diminished with other noninvasive screening modalities¹³—and higher patient participation in both initial screening^14,15 and follow-up colonoscopy¹⁶ when needed.

A responsibility to evolve

Together, these data show how noninvasive screening and colonoscopy can work in tandem to deliver better short- and long-term outcomes. By prioritizing next-generation mt-sDNA tests for average-risk screening and reserving colonoscopy for follow-up and intervention, we can reduce system strain and reach more patients.

With compelling evidence before us, we have both the opportunity—and the responsibility—to evolve CRC screening in ways that can ultimately save more lives.

References:

1. Gangwani MK, Aziz A, Dahiya DS, Nawras M, Aziz M, Inamdar S. History of colonoscopy and technological advances: a narrative review. Transl Gastroenterol Hepatol. 2023;8:18. Published 2023 Apr 20. doi:10.21037/tgh-23-4.
2. Ebner DW, Kisiel JB, Fendrick AM, et al. Estimated Average-Risk Colorectal Cancer Screening-Eligible Population in the US. JAMA Netw Open. 2024;7:e245537.
3. Joseph DA, Meester RG, Zauber AG, et al. Colorectal cancer screening: Estimated future colonoscopy need and current volume and capacity. Cancer. 2016;122:2479-86.
4. Workforce projections. Health Resources and Services Administration. U.S. Department of Health and Human Services. https://data.hrsa.gov/topics/health-workforce/workforce-projections. Accessed April 20, 2026. 
5. Wolf AMD, Hoffman RM, Walter LC, et al. Colorectal cancer screening: an update to the American Cancer Society guideline, 2026. CA Cancer J Clin. 2026;e70083. doi:10.3322/caac.70083.
6. Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):25–281. doi:10.3322/caac.21457.
7. American Cancer Society. Cancer Facts & Figures 2026. Atlanta: American Cancer Society; 2026.
8. Ladabaum U, Weinberg DS, Castells A. Can colonoscopy still be promoted as the best choice for colorectal cancer screening? Gastroenterology. 2026;170(3):456-462. doi: 10.1053/j.gastro.2025.12.026
9. Fendrick AM, Kurlander JE, Vahdat V, Estes C, Gohil S, Limburg PJ, Lieberman DA. Optimizing colonoscopy capacity to maximize colorectal cancer outcomes. Gastro Hep Adv. 2026. doi: 10.1016/j.gastha.2026.100930.
10. Fendrick AM, Kurlander JE, Vahdat V, Estes C, Gohil S, Limburg PJ, Lieberman DA. Optimizing colonoscopy capacity to maximize colorectal cancer outcomes. Gastro Hep Adv. 2026. [Supplementary material, Table S3]. doi: 10.1016/j.gastha.2026.100930.
11. Dore M, Ebner DW, Vahdat V, Estes C, Ozbay AB, Foster V, Limburg PJ. Model-based evaluation of colorectal cancer screening effectiveness: three rounds of multitarget stool DNA testing versus one colonoscopy. J Med Econ. 2026;29(1):986-993. doi:10.1080/13696998.2026.2645491
12. Imperiale TF, Porter K, Zella J, et al. Next-Generation Multitarget Stool DNA Test for Colorectal Cancer Screening. N Engl J Med. 2024;390(11): 984-993. doi:10.1056/NEJMoa2310336.
13. Chung DC, Gray DM 2nd, Singh H, et al. A cell-free DNA blood-based test for colorectal cancer screening. N Engl J Med. 2024;390(11):973-983. doi:10.1056/NEJMoa2304714.
14. Le QA, Greene M, Gohil S, et al. Adherence to multi-target stool DNA testing for colorectal cancer screening in the United States. Int J Colorectal Dis. 2025;40(1):16.
15. Singal AG, Gupta S, Skinner CS, et al. Effect of Colonoscopy Outreach vs Fecal Immunochemical Test Outreach on Colorectal Cancer Screening Completion: A Randomized Clinical Trial. JAMA. 2017; 318: 806–815. DOI: 10.1001/jama.2017.11389.
16. Austin G, Kowalkowski H, Guo Y, et al. Patterns of initial colorectal cancer screenings after turning 50 years old and follow-up rates of colonoscopy after a positive stool-based testing among the average-risk population. Curr Med Res Opin. 2023;39(1):47-61.