Colorectal Cancer Screening in the United States: What Is the Best FIT?

The analysis of the optimal method for colorectal cancer screening rightly highlighted missing prerequisites (access at no cost to all and, a national infrastructure to monitor the quality for different steps) but it deserves comment.
First, in France, calls for screening were published in 1995 (results of two 1996 Lancet’s papers being available in 1994).(2) However, the free organized national program with guaiac only began in 2003 for 23 districts with generalisation to all 100 in the late 2008. In 2015, just before the switch from guaiac to fecal immunochemical testing (FIT,) participation rate is only 29%.
Second, the choice of the method is not binary: colonoscopy vs FIT. Do gastroenterologists or radiologists rely on FIT for themselves? President Obama, at the early age of 49, choose virtual CT-colonography after its first election!(3) A well designed and robust randomized control trial has just reported preliminary results comparing FIT, endoscopy and CT-colonography with reduced preparation.(4) Dectection rates for advanced neoplasia are: FIT (1.7% for first-round) 5.5% for CT-colonography and 7.2% for endoscopy. The American Cancer Society “prefers the tests that are designed to find both early cancer and polyps: Flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years, or double-contrast barium enema every 5 years, or CT colonography (virtual colonoscopy).”(https://www.cancer.org/cancer/colon-rectal-cancer/early-detection/acs-recommendations.html last revised June 24, 2016) Uptake is the most critical barrier and the solution is simple, provide the patient the choice of the test he is willing and able to complete with high fidelity.
Third, a society can be judged by how fairly health is distributed across the social spectrum. Age-specific prevalence for advanced colorectal neoplasms is more than twice higher in men than in women but no recommendations for screening take this into account.(5) Why men are discriminated?
Last, cancer prevention should be a comprehensive framework but no screening program associate care and cure for smoking and obesity yet.

1 Weinberg DS, Barkun A, Turner BJ. Colorectal cancer screening in the United States: What is the best FIT? Ann Intern Med. 2017;166:297-298.
2 Dubois G. Screening for colorectal cancer. French Working Group on Colorectal Cancer Screening. N Engl J Med 1995;333:460-1
3 Braillon A. Colorectal cancer screening: from perspectives to reality. Gastroenterology. 2010;139:1065.
4 Sali LMM, Falchini M, Ventura L, et al. Reduced and full-preparation CT colonography, fecal immunochemical test and colonoscopy for population screening of colorectal cancer: a randomized trial. J Natl Cancer Inst 2016;108 (2):djv319.
5 Brenner H, Altenhofen L, Hoffmeister M. Sex, age, and birth cohort effects in colorectal neoplasms: a cohort analysis. Ann Intern Med 2010;152:697-703.