3. Screening ages and tests
Screening ages and tests summary recommendation ...
Issued on: June 2025
This overarching recommendation is the result of a structured, step-by-step approach wherein the ECICC Working Group evaluated and finalised decisions on colorectal cancer screening age ranges, optimal test frequency, and comparisons across tests. To ensure a comprehensive understanding, it is essential to consider this recommendation in the context of the supporting recommendations and documentation, which will be published soon.
Healthcare question
Should faecal immunochemical test, flexible sigmoidoscopy, or colonoscopy be used for colorectal cancer screening in asymptomatic average risk adults?
Recommendation
The ECICC Working Group (WG) recommends organised, population-based colorectal cancer screening programmes for all average-risk adults aged 50 to 69 (strong recommendation, moderate certainty of the evidence). As the preferred approach, the WG suggests screening with Fecal Immunochemical Test (FIT) every two years, and continuing until the age of 74 (conditional recommendations, low certainty of the evidence).
If FIT is not implemented, the WG suggests endoscopy-based screening until the age of 69 and using colonoscopy every 15 years over flexible sigmoidoscopy every 10 years (conditional recommendation, low certainty of evidence), which are both conditionally recommended.
The WG also suggests no screening for adults under the age of 50 (conditional recommendations, very low certainty of the evidence).
Justification
The WG agreed on this recommendation by consensus.
The WG judged that the balance between desirable and undesirable effects and cost-effectiveness probably favours FIT screening as compared to other screening modalities. In addition, the WG judged that FIT screening will probably increase equity and acceptability, and it is feasible to implement.
Despite the variability in the estimates of colorectal cancer diagnosis and death and the low certainty in the evidence, the WG judged that the balance of effects probably favours colonoscopy over flexible sigmoidoscopy screening. The WG noted that variability may exist across different stakeholders in the acceptability of these two screening tests; for example, flexible sigmoidoscopy may be more acceptable to patients, while colonoscopy may be more acceptable to healthcare professionals.
Subgroup considerations
This recommendation is for the general population of asymptomatic adults at average risk of developing colorectal cancer.
Ongoing activities of the ECICC will address whether more nuanced risk-based screening approaches can be applied, including, for example, the use of different FIT test positivity thresholds based on participants’ characteristics (e.g. age, sex) or using the quantitative information of FIT results in previous rounds to modulate the interval or to offer different tests.
Considerations for implementation and policy making
Screening programmes should consider the availability of these tests while implementing this recommendation.
The FIT cut-off for test positivity could be tailored depending on the capacity to perform follow-up colonoscopies while also considering that increasing the cut-off would result in a decrease in screening benefits.
Monitoring and evaluation
Within the ECICC, quality indicators for this recommendation are under development.
Research priorities
Conducting studies aiming at:
- providing evidence on the direct comparison between FIT, colonoscopy and flexible sigmoidoscopy including data on the relevant intermediate outcomes;
- examining the impact of considering prior screening history to inform the selection of the screening approach;
- assessing the additional benefit of colonoscopy in detecting proximal lesions and the impact on interval cancers in the proximal colon;
- investigating the effectiveness of screening strategies using different tests, in combination or in separate screening rounds;
- investigating which characteristics and factors may have an impact on participation to colorectal cancer screening programmes (e.g. in people with low socio-economic status);
- investigating the effectiveness of new molecular-driven screening approaches, such as, for example, the ones based on cell-free DNA, gut microbiome composition, or miRNA signatures.
Supporting material