Around 1 in 4 people develop colorectal adenomas by age 60, and those with intermediate-risk growths face a 3-4 fold increased risk of cancer, yet the standard surveillance method—colonoscopy—is costly, imperfect, and already overwhelming NHS endoscopy services. This research tests whether a simple stool test, called faecal immunochemical testing (FIT), can replace routine colonoscopy for monitoring people at increased risk of bowel cancer. Unlike the older test used in the NHS Bowel Cancer Screening Programme, FIT is more sensitive for detecting advanced adenomas and early cancers. Crucially, its positivity threshold can be set low to minimise missed lesions, meaning only patients with a positive FIT would need to undergo colonoscopy. If successful, this approach could transform a strained medical infrastructure. It would free up endoscopy capacity for those who need it most, reduce patient discomfort and procedural risks, and lower healthcare costs—all while maintaining or improving cancer detection in a high-risk group. The result would be a safer, more acceptable, and cost-effective surveillance pathway that keeps a critical diagnostic system running efficiently without compromising patient outcomes.
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Around 1 in 4 people develop colorectal adenomas by age 60. Most of these are innocuous and only a minority will progress to cancer. However, people with intermediate risk adenomas remain at a 3-4 fold increased risk of developing cancer. Colonoscopy surveillance is therefore recommended for this group. Although colonoscopy is considered the gold standard bowel examination, it is not perfect. It can miss lesions and it is also a costly procedure with some risks to the patient. Furthermore, the roll out of the BCSP to all people aged 60-74 years and the increased number of colonoscopies being undertaken for surveillance is already overwhelming the endoscopy service. Given all these shortcomings of colonoscopy as a method of surveillance it is important that an alternative method is investigated. A new type of occult blood test (faecal immunochemical test, FIT) has become available that is more sensitive for the detection of colorectal cancer and advanced adenomas compared to the gFOBT used in the BCSP. FITs have features that make them more attractive option for protecting higher risk groups. For instance, the threshold for positivity can be set at a low level to minimise the risk of missing significant lesions. If this approach was found to be successful, only patients who had a positive FIT would need to be offered colonoscopy. We therefore propose that FIT may constitute a safer, more acceptable and cost-effective method than colonoscopy for surveillance of people at increased risk of developing colorectal cancer.
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