Shared Decision Making for Colorectal Cancer Screening Tests

Kenny Lin, MD, MPH
December 1, 2025

Most of the major cancer types have a single recommended screening test. For breast cancer, it’s mammography. For cervical cancer, cytology and/or human papillomavirus testing. For lung cancer, it’s low-dose computed tomography (CT). Colorectal cancer is unique in that physicians and patients have a menu of acceptable screening options, ranging from various stool-based tests to CT colonography, colonoscopy, and most recently, a blood test for circulating tumor DNA.

Guidelines recommend shared decision-making with average-risk adults 45 to 75 years of age to select a colorectal cancer screening strategy that aligns with patients’ preferences and values. A recent scoping review of 28 studies in the United States and Canada explored factors that play vital roles in these conversations. Researchers identified four domains that influence patients’ decision-making: test attributes (accuracy, cost, convenience, and complications); recommendations from their personal physician; fear, discomfort, and embarrassment for some regarding colonoscopy and stool tests; and external factors (culture, family input, socioeconomic status, and transportation access).

The US Preventive Services Task Force assigned a C grade (offer selectively, individualized decision) to colorectal cancer screening in adults 76 to 85 years of age due to a small net benefit of screening in this age group. A cluster randomized trial in older adults evaluated the effect of physician training in shared decision-making on receipt of patient-preferred colorectal cancer screening (which could include no testing) and on overall screening rates. At 12 months, about one-half of patients in each group had received their preferred approach, with no significant difference between the groups in test uptake.

A pitfall for clinicians is limiting patients’ test options to colonoscopy because of a belief that it is the “gold standard” test, even though no data have demonstrated clear superiority over fecal immunochemical tests. An editorial in the September 2025 issue of American Family Physician discussed optimizing the role of noninvasive colorectal cancer screening tests, and an editorial in the October 2025 issue reflected on downsides of colonoscopy as a primary screening strategy. For patients who choose to undergo colonoscopy, adherence to evidence-based surveillance guidelines is critical to preventing harms associated with repeating colonoscopy at inappropriately short intervals.