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Review
. 2025 May 20;14(1):2501851.
doi: 10.1080/1758194X.2025.2501851. eCollection 2025.

Stratified/risk-based screening for colorectal cancer in the UK: an overview

Affiliations
Review

Stratified/risk-based screening for colorectal cancer in the UK: an overview

Susanne Maxwell et al. Colorectal Cancer. .

Abstract

While colorectal cancer screening is well-established in the UK, at present, it uses a 'one-size fits-all' approach - that is, individual risk is not considered when determining screening regimens (except for some specific conditions such as Lynch syndrome). Stratified screening offers the prospect of directing more intensive screening toward those at higher risk - with a corresponding reduction of screening intensity among lower-risk individuals. Two key opportunities for stratifying colorectal cancer screening are (1) making better use of an individual's quantitative fecal hemoglobin result rather than the current approach of deeming tests to be positive over an arbitrary threshold and (2) gathering information on lifestyle, family history, genetics and other factors to establish risk of colorectal cancer - and using this information to tailor screening regimens. While there is encouraging evidence from modeling studies demonstrating reduced colonoscopy requirements and increased positive prediction of colorectal cancer when incorporating risk assessments within screening, we need 'real world' evidence on stratified screening to establish whether it is effective, improves screening outcomes and is acceptable to the public. We also need to know the impact these changes would have on existing screening programs, and how programs might adapt their organizational and IT processes.

Keywords: Colorectal cancer; genetic testing; personal bowel cancer risk; risk-based colorectal screening; stratified screening.

Plain language summary

Bowel cancer is the fourth most common cancer in the UK. Bowel screening aims to find cancer early or find changes in the bowel (polyps) before they develop into cancer. The bowel screening test is called fecal immunochemical test (FIT) and is completed at home and sent away to detect tiny traces of blood in the stool. The level of these traces of blood is called the fecal hemoglobin (f-HB) level. If the f-HB level is above a set amount patients will be offered further testing which may include a colonoscopy. Not all people have the same risk of bowel cancer – some people have a higher risk, some lower. Despite these differences in risk, at present, everyone gets offered the same screening. There could be options to improve screening based on a person’s unique risk. This could be through increasing screening in higher risk people or reducing screening for people who are lower risk. Deciding an individual’s risk could be done in two ways (1) using the f-HB level rather than a ‘positive or ‘negative’ result. (2) Using lifestyle or personal factors such as their age or sex or their genetic make-up. This article reviews the evidence for changing the screening process based on an individual’s risk and what further information is needed before this can be put in place.

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Conflict of interest statement

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

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