The United Kingdom was one of the first countries in the world to have a fully rolled out colorectal cancer screening programme and, although the four constituent countries have taken somewhat different approaches, they all commenced with guaiac faecal occult blood testing and have all now transitioned to faecal immunochemical testing. In this Commentary, we trace the development of the Scottish Bowel Screening Programme, with reference to the other UK programmes, reflect on its successes and shortcomings, and make suggestions for the future.
HewitsonPGlasziouPWatsonE, et al.Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update. Am J Gastroenterol2008; 103: 1541–1549.
2.
SteeleRJCParkerRPatnickJ, et al.A demonstration pilot for colorectal cancer screening in the UK – a new concept in the introduction of health care strategies. J Med Screen2001; 8: 197–202.
3.
FraserCGMatthewCMMowatNAG, et al.Evaluation of a card collection based faecal immunochemical test in screening for colorectal cancer using a two-tier reflex approach. Gut2007; 56: 1415–1418.
4.
YoungGPSymondsELAllisonJE, et al.Advances in fecal occult blood tests: the FIT revolution. Dig Dis Sci2015; 60: 609–622.
5.
SteeleRJCMcDonaldPJDigbyJ, et al.Clinical outcomes using a faecal immunochemical test for haemoglobin in a national colorectal cancer screening programme constrained by colonoscopy capacity. United Eur Gastroenterol J2013; 1: 198–205.
6.
MossSMathewsCDayTJ, et al.Increased uptake and improved outcomes of bowel cancer screening with a faecal immunochemical test: results from a pilot study within the national screening programme in England. Gut2017; 66: 1631–1644.
7.
ClarkGStrachanJACareyFA, et al.Transition to quantitative faecal immunochemical testing from guaiac faecal occult blood testing in a fully rolled-out population-based national bowel screening programme. Gut2021; 70: 106–113.
8.
BurrNEDerbyshireETaylorJ, et al.Variation in post-colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study. Br Med J2019; 367: l6090.
9.
QuynAJFraserCGStannersG, et al.Scottish bowel screening programme colonoscopy quality – scope for improvement?Colorectal Dis2018; 20: O277–O283.
10.
WinterJClarkGSteeleR, et al.Postcolonoscopy cancer rates in Scotland from 2012 to 2018: a population-based cohort study. Colorectal Dis2025; 27: e17298.
11.
AtkinWWooldrageKParkinDM, et al.Long term effects of once-only flexible sigmoidoscopy screening after 17 years of follow-up: the UK flexible sigmoidoscopy screening randomised controlled trial. Lancet2017; 389: 1299–1311.
QuynAJFraserCGStannersG, et al.Uptake trends in the Scottish bowel screening programme and the influences of age, sex and deprivation. J Med Screen2018; 25: 529–534.
14.
KarsaLPatnickJSegnanN. European Commission, Directorate-General for Health and Consumers, Executive Agency for Health and Consumers, World Health Organization. In: KarsaLPatnickJSegnanN (eds) European guidelines for quality assurance in colorectal cancer screening and diagnosis. Publications Office, 2010. https://data.europa.eu/doi/10.2772/1458.
15.
WongMCSHuangJHuangJLW, et al.Global prevalence of colorectal neoplasia: a systematic review and meta-analysis. Clin Gastroenterol Hepatol2020; 18: 553–561.
16.
Personal Communication from G Clark, Public Health Scotland. Opt-in over upper age range report.
17.
DuffySVulkanDCuckleH, et al.Effect of annual mammographic screening from age 40 years on breast cancer mortality (UK age trial): final results of a randomised, controlled trial. Lancet Oncol2020; 21: 1165–1172.
18.
LibbyGBrayJChampionJ, et al.Pre-notification increases uptake of colorectal cancer screening in all demographic groups: a randomised controlled trial. J Med Screen2011; 18: 24–29.
19.
RobbKAYoungBMurphyMK, et al.Behavioural interventions to increase uptake of FIT colorectal screening in Scotland (TEMPO): a nationwide, eight-arm, factorial, randomised controlled trial. Lancet. DOI: https://doi.org/10.1016/ S0140-6736(24)02813-7. Published Online March 12, 2025.
SteeleRJCMcClementsPWatlingC, et al.Interval cancers in a FOBT-based colorectal cancer population screening programme: implications for stage, gender and tumour site. Gut2012; 61: 576–581.
22.
WhyteSThomasCKearnsB, et al.Optimising bowel cancer screening phase 1: optimising the cost effectiveness of repeated FIT screening and screening strategies combining bowel scope and FIT screening. University of Sheffield 2018. https://view-health-screening-recommendations.service.gov.uk/bowel-cancer/ (accessed 1 February 2025).
23.
ClarkGRGodfreyTPurdieC, et al.Interval cancers in a national colorectal screening programme based on faecal immunochemical testing: implications for faecal haemoglobin concentration threshold and sex inequality. J Med Screen2024; 31: 21–27.
24.
DeprezLPiggottCvan der HagenEAE, et al.IFCC Working group on fecal immunochemical testing (WG FIT). Comparison and commutability study among four faecal immunochemical tests (FIT) systems. Clin Chem Lab Med2023; 62: 50–59.
25.
ClarkGRSteeleRJFraserCG. Do faecal test-based colorectal cancer screening pilots provide data that are reflected in subsequent programmes? Evidence from interval cancer proportions. Ann Clin Biochem2022; 59: 450–452.
26.
Toes-ZoutendijkEvan LeerdamMEDekkerE, et al.Real-time monitoring of results during first year of Dutch colorectal cancer screening program and optimization by altering fecal immunochemical test cut-off levels. Gastroenterology2017; 152: 767–775.
27.
SteeleRJCMcClementsPLLibbyG, et al.Results from the first three rounds of the Scottish demonstration pilot of FOBT screening for colorectal cancer. Gut2009; 58: 530–535.
28.
ClarkGRCFraserCGStrachanJA, et al.Sex variation in colorectal cancer mortality; trends and implications for screening. Eur J Public Health2023; 33: 331–335.
29.
ClarkGRCSteeleRJCFraserCG. Strategies to minimise the current disadvantages experienced by women in faecal immunochemical test-based colorectal cancer screening. Clin Chem Lab Med2022; 60: 1496–1505.
30.
ClarkGRCStrachanJAMcPhersonA, et al.Faecal haemoglobin distributions by sex, age, deprivation and geographical region: consequences for colorectal cancer screening strategies. Clin Chem Lab Med2020; 58: 2073–2080.
31.
BlomJLöwbeerCElfströmKM, et al.Gender-specific cut-offs in colorectal cancer screening with FIT: increased compliance and equal positivity rate. J Med Screen2019; 26: 92–97.
32.
ZauberAGWinawerSJO'BrienMJ. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med2012; 366: 687–696.
33.
ClarkGRAndersonASGodfreyTG, et al.Variation in changes in the incidence of colorectal cancer by age and association with screening uptake: an observational study. BMJ Open2020; 10: e037925.
34.
SekiguchiMWesterbergMEkbomA, et al.Endoscopist characteristics and polyp detection in colonoscopy: cross-sectional analyses of screening of Swedish colons. Gastroenterology2023; 164: 293–295.
35.
MonahanKJDaviesMMAbulafiM, et al.Faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC): a joint guideline from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG). Gut2022; 71: 1939–1962.
36.
DigbyJStrachanJAMcCannR, et al.Measurement of faecal haemoglobin with a faecal immunochemical test can assist in defining which patients attending primary care with rectal bleeding require urgent referral. Ann Clin Biochem2020; 57: 325–327.
37.
RutterMDEastJReesCJ, et al.British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England post-polypectomy and post-colorectal cancer resection surveillance guidelines. Gut2020; 69: 201–223.
38.
BerwaldGYoungGPCockC, et al.The diagnostic performance of fecal immunochemical tests for detecting advanced neoplasia at surveillance colonoscopy. Clin Gastroenterol Hepatol2023; 22: 878–885.
39.
MowatCDigbyJClearyS, et al.Faecal haemoglobin concentration in adenoma, before and after polypectomy, approaches the ideal tumour marker. Ann Clin Biochem2022; 59: 272–276.
40.
Bjørsum-MeyerTKoulaouzidisABaatrupG. The optimal use of colon capsule endoscopes in clinical practice. Ther Adv Chronic Dis2022; 13: 20406223221137501.
41.
MalmqvistJSiersmaVDHestbechMS, et al.Short and long-term psychosocial consequences of participating in a colorectal cancer screening programme: a matched longitudinal study. BMJ Evid Based Med2022; 27: 87–96.
LarsenIKGrtomolTAlmendingenK, et al.Impact of colorectal cancer screening on future lifestyle choices: a three-year randomised controlled trial. Clin Gastroenterol Hepatol2007; 7: 477–483.
44.
AndersonASCraigieACaswellS, et al.The impact of a body weight and physical activity weight loss intervention (BeWEL) initiated through a national colorectal cancer screening programme. Br Med J2014; 348: g1823.
45.
DigbyJFraserCGClarkG, et al.Improved use of faecal immunochemical tests for haemoglobin in the Scottish bowel screening programmeJ Med Screen2023;30:184–190
46.
DigbyJFraserCGCareyF, et al.Can the performance of a quantitative FIT-based colorectal cancer screening programme be enhanced by lowering the threshold and increasing the interval?Gut2018; 67: 993–999.
47.
HuntleyCTorrBSudA, et al.Utility of polygenic risk scores in UK cancer screening: a modelling analysis. Lancet Oncol2023; 24: 658–668.
48.
ImperialeTFRansohoffDFItzkowitzS, et al.Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med2014; 370: 1287–1297.
49.
KleinEARichardsDCohnA, et al.Clinical validation of a targeted methylation-based multi-cancer early detection test using an independent validation set. Ann Oncol2021; 32: 1167–1177.
50.
ChandrapalanSBoschSCubiellaJ, et al.Systematic review with meta-analysis: volatile organic compound analysis to improve faecal immunochemical testing in the detection of colorectal cancer. Aliment Pharmacol Ther2021; 54: 14–23.
51.
FraserCG. Faecal haemoglobin: measurement, applications, and future potential. Best Pract Res Clin Gastroenterol2023; 66: 101833.
