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Am Fam Physician. 2023;107(6):642-644

Author disclosure: No relevant financial relationships.

Clinical Question

Does screening with colonoscopy result in an increased diagnosis of colorectal cancer and a larger reduction in mortality compared with the sequential use of fecal immunochemical testing (FIT)?

Evidence-Based Answer

No trials have directly compared colonoscopy and sequential FIT. The U.S. Preventive Services Task Force (USPSTF) estimates that, over a lifetime, using colonoscopy compared with FIT may avert one additional death for every approximately 500 people screened starting at 50 years of age. (Strength of Recommendation [SOR]: C, estimate from modeling projections.) There are conflicting mortality data for colonoscopy. Several cohort studies found a 68% reduced mortality compared with no screening (SOR: B, two cohort studies with long follow-up periods.); however, a recent large European randomized controlled trial (RCT) found no colorectal cancer–specific mortality reduction from colonoscopy when using an intention-to-treat analysis. (SOR: B, single large RCT.) FIT reduced colorectal cancer– specific mortality by 16% to 62% compared with no screening. (SOR: B, older RCTs and one large cohort study.)

Evidence Summary

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Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (

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This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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