Adherence to follow-up after a positive fecal occult blood test in an organized colorectal cancer screening program in Korea, 2004-2008

Background and Aim: To investigate the participation rates, positivity rates, and follow‐up rates from 2004 to 2008 in an organized colorectal cancer (CRC) screening program using a fecal occult blood test (FOBT) in Korea. Methods: The study population was men and women aged 50 years or older who were invited to participate in the National Cancer Screening Program for CRC between 1 January 2004 and 31 December 2008. We collected the FOBT results and follow‐up information for the FOBT positives. Results: Participation rates increased steadily each year from 10.5% in 2004 to 21.1% in 2008. Between 2004 and 2008, FOBT positivity rates declined from 8.0% to 6.8%. Among the FOBT‐positives, 61.3% of participants underwent either colonoscopy or double contrast barium enema (DCBE) in 2004, and this rate decreased to 38.6% in 2008. Age, health insurance type, and screening history were associated with adherence to follow‐up test after a positive FOBT. With regard to follow‐up tests, colonoscopy rates increased from 17.9% in 2004 to 27.6% in 2008, while DCBE decreased from 43.4% in 2004 to 11.0% in 2008. Colonoscopy was significantly more likely to be chosen as a follow‐up test by men, participants aged 50–59 years, and National Health Insurance beneficiaries. Conclusion: These findings suggest that targeting participants for follow‐up, based on age and previous screening history, could be a good way to improve the follow‐up rate.     

Survival of elderly persons undergoing colonoscopy: implications for colorectal cancer screening and surveillance

BACKGROUND: In the elderly, the increased prevalence of colorectal neoplasia and the protective effect of colonoscopy may be offset by advancing age and comorbidity. OBJECTIVE: To describe and quantify the endoscopic findings, survival, and predictors of mortality of elderly persons after colonoscopy. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of persons aged>or=75 years who underwent colonoscopy in 1999 and 2000 at a U.S. Veterans Affairs facility and urban county hospital. MAIN OUTCOME MEASURES: Advanced neoplasms were defined as colorectal cancer (CRC), polyp with high-grade dysplasia, villous histologic features, or tubular adenoma>or=1 cm. Comorbidity was measured with the Charlson comorbidity index. Subjects were followed until death or study closure. RESULTS: Of 469 eligible subjects, 65 were excluded and 404 were included in the study. Fifty-nine of 404 (15%) had an advanced neoplasm, including 8 (2%) with CRC. There were 167 deaths (41%); the mean overall survival was 4.1+/-0.1 years (median 5.95 years). A symptomatic indication for colonoscopy was not predictive of death. Mortality was predicted by age (hazard ratio 1.16 for each year increase beyond age 75 years, 95% CI 1.07-1.3, P=.0003) and Charlson score (hazard ratio 8.3 for each point increase, 95% CI 1.4-48.5, P=.02). The median survival of patients aged 75 to 79 years was >5 years if the Charlson score was or=80 years, the median survival was <5 years regardless of Charlson score. LIMITATIONS: Retrospective design. CONCLUSIONS: In this cohort of elders, age and comorbidity were predictors of death. The protective effect of younger age lessens as comorbidity increases. These findings may have important implications for CRC screening and surveillance in elders.     

CT colonography: role in FOBT-based screening programs for colorectal cancer

Computed tomographic colonography (CTC) is a minimally invasive imaging examination for the colon, and is safe, well tolerated and accurate for the detection of colorectal cancer (CRC) and advanced adenoma. While the role of CTC as a primary test for population screening of CRC is under investigation, the fecal occult blood test (FOBT) has been recommended for population screening of CRC in Europe. Subjects with positive FOBT are invited to undergo total colonoscopy, which has some critical issues, such as suboptimal compliance, contraindications and the possibility of an incomplete exploration of the colon. Based on available data, the integration of CTC in FOBT-based population screening programs for CRC may fall into three scenarios. First, CTC is recommended in FOBT-positive subjects when colonoscopy is refused, incomplete or contraindicated. For these indications CTC should replace double-contrast barium enema. Second, conversely, CTC is not currently recommended as a second-level examination prior to colonoscopy in all FOBT-positive subjects, as this strategy is most probably not cost-effective. Finally, CTC may be considered instead of colonoscopy for surveillance after adenoma removal, but specific studies are needed.     

上海松江区结直肠癌普查研究的初步结果

目的探讨粪便隐血试验结合大肠镜检查作为大肠癌普查方式的可行性。方法2006年9月至2007年5月,对上海市松江区无症状且结直肠癌普通危险度的≥50岁人群以及40～49岁志愿参加普查者行免疫组化法粪便隐血试验,连续3次排便中任意2次粪便标本送检,对任何1次粪便隐血阳性（包括弱阳性）的患者行全结肠镜检查。对息肉的数量、分布位置及病理结果进行统计。结果≥50岁受检者共2692例,粪便隐血试验阳性者184例,阳性率6．8％,共56例患者发现了64枚结肠息肉,包括腺瘤性息肉34枚、炎性息肉15枚、增生性息肉15枚,发现直肠癌1例。40～49岁志愿普查者共582例,隐血试验呈阳性者28例,阳性率4．8％,共6例患者发现了6枚息肉,包括腺瘤性息肉1枚、炎性息肉5枚,并发现肠癌2例。多数息肉分布于左半结肠。结论对无症状的结直肠癌普通危险度人群的普查能较早发现结肠息肉,对粪便隐血试验阳性的患者行全结肠镜检查可能较适合社区及广大农村地区结直肠癌的大规模普查。     

CT colonography after incomplete colonoscopy in subjects with positive faecal occult blood test

AIM： To report our experience with computed tomography colonography （CTC） systematically performed in subjects with positive faecal occult blood test （FOBT） and an incomplete colonoscopy in the setting of a population-based screening for colorectal cancer （CRC）.
METHODS： From April 2006 to April 2007, 43 290 individuals （age range 50-70） who adhered to the regional screening program for the prevention of CRC underwent immunochemical FOBT. FOBT was positive in 1882 subjects （4.3%）. 1463 （77.7%） of these subjects underwent colonoscopy, 903 performed in a single center. Of 903 colonoscopies 65 （7.2%） were incomplete. Forty-two of these subjects underwent CTC. CTC was performed with a 16-MDCT scanner after standard bowel prep （polyethyleneglycole） in both supine and prone position. Subjects whose CTC showed polyps or masses were referred to the endoscopist for repeat colonoscopy under sedation or underwent surgery. Perlesion and per-segment positive predictive values （PPV） were calculated.
RESULTS： Twenty-one （50%） of 42 CTCs showed polyps or masses. Fifty-five of these subjects underwent a repeat colonoscopy, whereas 2 subjects underwent surgery for colonic masses of indeterminate nature. Four subjects refused further examinations. CTC correctly identified 2 colonic masses and 20 polyps. PPV for masses or polyps greater than 9 mm was of 87.5%. Per-lesion and per-segment PPV were, respectively, 83.3% and 83.3% for polyps greater or equal to 10 mm, and 77.8% and 85.7% for polyps of 6-9 mm.
CONCLUSION： In the context of a screening program for CRC based on FOBT, CTC shows high per-segment and per-lesion PPV for colonic masses and polyps greater than 9 mm. Therefore, CTC has the potential to become a useful technique for evaluation of the non visualized part of the colon after incomplete colonoscopy.     

Sensitivity, Specificity, and Predictive Value of Fecal Occult Blood Testing (Hemoccult II) for Colorectal Neoplasia in Symptomatic Patients: A Prospective Study with Total Colonoscopy

Objective: To evaluate the specificity, sensitivity, and positive predictive value of fecal occult blood testing (FOBT) in symptomatic patients, with colonoscopy as the gold standard, and to assess the usefulness of FOBT as an ancillary examination in symptomatic patients for whom total colonoscopy is indicated.
Methods: We studied 439 consecutive patients who underwent Hemoccult II testing before total colonoscopy.
Results: The sensitivity, specificity, and positive predictive value for colorectal neoplasia (cancer and adenomatous polyps) was 76.5%, 56.7%, and 27.6%, respectively. The sensitivity, specificity, and positive predictive value for colorectal cancer were 69.2%, 73.2%, and 7.3%, respectively.
Conclusions: The sensitivity, specificity, and positive predictive value of FOBT are difficult to estimate from screening programs, because Hemoccult-negative individuals do not undergo examination of the colon, and many of the Hemoccult-positive cases do not undergo total colonoscopy. With total colonoscopy serving as the gold standard, FOBT does not appear to be of much value as an ancillary examination in patients with symptoms potentially attributable to the lower gastrointestinal tract.     

Barriers to colorectal cancer screening： A case-control study

AIM： To investigate barriers to colorectal cancer （CRC） screening in a community population. METHODS： We conducted a community-based case-control study in an urban Chinese population by questionnaire. Cases were selected from those completing both a fecal occult blood test （FOBT） case and colonoscopy in a CRC screening program in 2004. Control groups were matched by gender, age group and community. Control 1 included those having a positive FOBT but refusing a colonoscopy. Control 2 included those who refused both an FOBT and colonoscopy. RESULTS： The impact of occupation on willingness to attend a colorectal screening program differed by gender. P for heterogeneity was 0.009 for case vs control group 1, 0.01 for case versus control group 2, and 0.80 for control group 1 vs 2. Poor awareness of CRC and its screening program, characteristics of screening tests, and lack of time affected thescreening rate. Financial support, fear of pain and bowel preparation were barriers to a colonoscopy as a screening test. Eighty-two percent of control group 1 and 87.1% of control group 2 were willing attend if the colonoscopy was free, but only 56.3% and 53.1%, respectively, if it was self-paid. Multivariate odds ratios for case vs control group 1 were 0.10 among those unwilling to attend a free colonoscopy and 0.50 among those unwilling to attend a self-paid colonoscopy. CONCLUSION： Raising the public awareness of CRC and its screening, integrating CRC screening into the health care system, and using a painless colonoscopy would increase its screening rate.     

Immunological fecal occult blood test vs. serum ferritin for detection of colorectal neoplasia in high risk asymptomatic population

Introduction: Fecal occult blood tests (FOBT) (biochemical or immunological) are based on the fact that most of the polyps or cancers bleed. Anemia due to iron deficiency is a wellknown sign for colorectal cancer (CRC). Ferritin is frequently used to select candidates for colonoscopy. Objective: To determine and compare the diagnostic value of immunological fecal occult blood test vs. ferritin for the detection of colorectal neoplasia (cancer or polyps) in high-risk patients. Methods: A transversal prospective study at National Cancer Institute, Mexico City, in consecutive asymptomatic subjects at high risk for CRC was performed, comparing two tests (immunological against serum ferritin) with colonoscopy plus histopathology. Both tests were performed in a blindly fashion previous to colonoscopy. Results: Fifty patients were included in the study; twenty-eight patients had colorectal neoplasia (21 CRC, 7 adenomas). All immunologic tests for fecaloccult blood were positive in patients with colorectal lesions (sensitivity, 98%). There was no difference between the mean ferritin levels in patients with CRC or adenomas vs. those with negative colonoscopy (p = 0.58). The cutoff point where significant relationship between serum ferritin levels and colon lesions was established was ?46 ng/mL. In anemic patients with serum ferritin levels <46 ng/mL, the test had a sensitivity 53%, specificity 86%, positive predictive value 83%, and negative predictive value of 59% (p = 0.003). Conclusions: The immunological FOBT is a better diagnostic tool than serum ferritin for screening of colonic neoplasms.     

Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

Background

Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.

Objective

To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).

Design

Population-based cohort study.

Participants

A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

Measures

Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.

Results

Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR?=?1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR?=?1.30; 95 % CI: 1.22–1.40).

Conclusions

Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.

     

Screening for colorectal cancer

A review of the literature regarding the screening strategies for colorectal cancer (CRC), particularly for average risk individuals, is analysed. The advantages and disadvantages or limitations of screening modalities for CRC, such as faecal occult blood testing (FOBT) with guaiac-based tests or the new faecal deoxyribonucleic acid tests, endoscopic screening by flexible sigmoidoscopy, colonoscopy, or CT-colonography and double contrast barium enema examination, are reported. The efficacy and cost of the screening tests are evaluated, and it is found that any of the suggested tests is more cost effective than other medical intervention or treatment as compared with no screening. The reported compliance to any form of screening test was 30-40%, a rate that is low enough. The experience of our surgical department of a screening programme, based on FOBT, on 4189 individuals over 50 years old, and application of colonoscopy in positive subjects, is reported.     

Potential impact of population-based colorectal cancer screening in Canada

Randomized controlled trials (RCT) have shown the efficacy of screening for colorectal cancer (CRC) using the faecal occult blood test (FOBT) with follow-up by colonoscopy. We evaluated the potential impact of population-based screening by FOBT followed by colonoscopy in Canada: mortality reduction, cost-effectiveness, and resource requirements. The microsimulation model POHEM was adapted to simulate CRC screening using Canadian data and RCT results about test sensitivity and specificity, participation, incidence, staging, progression, mortality and direct health care costs. In Canada, biennial screening of 67% of individuals aged 50-74 in the year 2000 resulted in an estimated 10-year CRC mortality reduction of 16.7%. The life expectancy of the cohort increased by 15 days on average and the demand for colonoscopy rose by 15% in the first year. The estimated cost of screening was $112 million per year or $11,907 per life-year gained (discounted at 5%). Potential effectiveness would depend on reaching target participation rates and finding resources to meet the demand for FOBT and colonoscopy. This work was conducted in support of the National Committee on Colorectal Cancer Screening.     

Perspectives of colorectal cancer screening in Germany 2009

Adequate screening methods can decrease colorectal cancer (CRC) mortality. The guaiac test for fecal occult-blood (FOBT) is part of the German CRC Screening Program since 1970 and has evidence level Ia. In randomized multicenter-studies FOBT has an average sensitivity of 24% and decreases CRC mortality up to 30%. Immunological tests for human haemoglobin (iFOBT) show better performance characteristics than guaiac FOBT, with augmented sensitivity and specificity. However, the single tests show wide differences in diagnostic performance and iFOBT is not yet covered by insurance companies although it should replace the guaiac test for CRC screening. Visual colonoscopy, which was introduced to the German National Cancer Screening Program in 2002, is the gold standard for the diagnosis of colorectal neoplasia. From 2003 to 2007 more than 2.8 million examinations have been documented in Germany. The prevalence of adenomas is around 20% and of CRC about 0.7% to 1.0% of the screenings. Seventy percent of the carcinomas detected during screening are in an early stage (UICC I and II). Furthermore, screening colonoscopy is a cost saving procedure with a low complication rate (0.25% overall). Insurance companies save 216€ for each screening colonoscopy mainly by prevention of neoplasia due to polypectomy. In Germany, virtual colonography by computed tomography (CT) or magnetic resonance imaging still lacks standardization of the hard and software. In experienced centres the sensitivity for CRC and large polyps of CT colonography is comparable to colonoscopy but in meta-analyses the ranking is lower. New technologies like computer-aided colonoscopies with sheath or double balloon techniques are coming up as well as capsule colonoscopy, which sensitivity for large polyps is about 70%. Advised by his physician, the patient can choose his most acceptable examination method from this whole set of screening tools.     

The Norwegian Colorectal Cancer Prevention (NORCCAP) screening study: baseline findings and implementations for clinical work-up in age groups 50-64 years

BACKGROUND: Randomized controlled trials of sufficient power testing the long-term effect of screening for colorectal neoplasia only exist for faecal occult blood testing (FOBT). There is indirect evidence that flexible sigmoidoscopy (FS) may have a greater yield. The aim of this study was to determine the diagnostic yield of screening with FS or a combination of FS and FOBT in an average-risk population in an urban and combined urban and rural population in Norway. METHODS: 20,780 men and women (1:1), aged 50-64 years, were invited for once-only screening (FS only or a combination of FS and FOBT (1:1)) by randomization from the population registry. A positive FS was defined as a finding of any neoplasia or any polyp > or = 10 mm. A positive FS or FOBT qualified for colonoscopy. RESULTS: Overall attendance was 65%. Forty-one (0.3%) cases of CRC were detected. Any adenoma was found in 2208 (17%) participants and 545 (4.2%) had high-risk adenomas. There was no difference in diagnostic yield between the FS and the FS and FOBT group regarding CRC or high-risk adenoma. Work-up load comprised 2821 colonoscopies in 2524 (20%) screenees and 10% of screenees were recommended later colonoscopy surveillance. There were no severe complications at FS, but six perforations after therapeutic colonoscopy (1:336). CONCLUSIONS: The present study bodes well for future management of a national screening programme, provided that follow-up results reflect adequate proof of a net benefit. It is highly questionable whether the addition of once-only FOBT to FS will contribute to this effect.     

A comparison of the immunochemical fecal occult blood test and total colonoscopy in the asymptomatic population

BACKGROUND & AIMS: The fecal occult blood test (FOBT) is recommended as a screening test for colorectal cancer, but there are few reliable studies on the accuracy of immunochemical FOBT. The aim of this study was to analyze the sensitivity of immunochemical FOBT and to compare the results with the findings from complete colonoscopy. METHODS: Asymptomatic adults underwent 1-time immunochemical FOBT and total colonoscopy simultaneously. The prevalence and location of colorectal neoplasia were determined by colonoscopy. The results of immunochemical FOBT and the colonoscopic findings were compared. RESULTS: Of 21,805 patients, immunochemical FOBT was positive in 1231 cases (5.6%). The sensitivity of 1-time immunochemical FOBT for detecting advanced neoplasia and invasive cancer was 27.1% and 65.8%, respectively. In addition, the sensitivity for invasive cancer according to Dukes' stage showed 50.0% for Dukes' stage A, 70.0% for Dukes' stage B, and 78.3% for Dukes' stages C or D. The sensitivity for detecting advanced neoplasia at the proximal colon was significantly lower than that detected in the distal colon (16.3% vs 30.7%, P = .00007). CONCLUSIONS: Although the screening of asymptomatic patients with immunochemical FOBT can identify patients with colorectal neoplasia to a certain extent, the sensitivity is relatively low and different according to the tumor location. Therefore, programmatic and repeated screening by immunochemical FOBT may be necessary to increase sensitivity for colorectal cancer detection.     

Are Physicians’ Recommendations For Colorectal Cancer Screening Guideline-Consistent?

BACKGROUND  

Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians’ recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.     

Better acceptance of Fecal Occult Blood Test (FOBT) for colorectal cancer screening during hospitalization

INTRODUCTION: Colorectal cancer (CRC) is a leading cause of illness and death in the Western world. Screening with fecal occult blood test (FOBT) significantly reduces the death rate and the incidence from CRC but these tests are not widely accepted. We investigated the possible contribution of hospitalization to a better acceptance of CRC screening. PATIENTS AND METHODS: From October 1998 through September 2000, 721 consecutive patients between 45 and 75 years of age admitted for various reasons were asked for participation in the study. They were asked to participate in FOBT-screening. In case of refusal of FOBT they were asked a second time after detailed information. In patients who accepted 3 consecutive FOBT's were performed. In case of positive FOBT results colonoscopy and gastroscopy were performed. RESULTS: 149 (82 male/67 female) patients were included. 94 (63.5%) of them agreed to undergo FOBT primarily and 10 (6.8%) secondarily after detailed information. The total acceptance rate of the FOBT was 69.8% (m/w : 69.1%/71.6%). In one of 5 cases with a positive FOBT result colorectal cancer (CRC) was diagnosed. Information on repetition of FOBT after one year could be obtained from 82 patients (55%). 37 patients (45%) had undergone repeated FOBT. None of the 37 patients was motivated by the FOBT screening during hospitalization. CONCLUSIONS: Staying in a hospital offers a good chance to achieve a higher acceptance of the FOBT. Therefore, hospitalization may contribute to a better colorectal cancer prevention. However, motivation to regularly repeat screening does not last in all patients. Therefore, public campaigns as well as medical counseling need to continuously stress the necessity of CRC screening procedures.     

Review in depth and meta-analysis of controlled trials on colorectal cancer screening by faecal occult blood test

BACKGROUND: Several randomized studies have shown that colorectal cancer (CRC) screening by faecal occult blood test (FOBT) reduces CRC mortality. These trials have different designs, especially concerning FOBT frequency and duration, as well as the length of follow-up after stopping FOBT campaigns. AIMS: To review the effectiveness of screening for CRC with FOBT, to consider the reduction in mortality during or after screening or to identify factors associated with a significant mortality reduction. METHODS: A systematic review of trials of FOBT screening with a meta-analysis of four controlled trials selected for their biennial and population-based design. The main outcome measurements were mortality relative risk (RR) and 95% confidence interval (CI) of biennial FOBT during short (10 years, i.e. five or six rounds) or long-term (six or more rounds) screening periods, as well as after stopping screening and follow-up during 5-7 years. The meta-analysis used the Mantel-Haenszel method with fixed effects when the heterogeneity test was not significant, and used 'intent to screen' results. RESULTS: Although the quality of the four trials was high, only three were randomized, and one used rehydrated biennial FOBT associated with a high colonoscopy rate (28%). A meta-analysis of mortality results showed that subjects allocated to screening had a reduction of CRC mortality during a 10-year period (RR 0.86; CI 0.79-0.94) although CRC mortality was not decreased during the 5-7 years after the 10-year (six rounds) screening period, nor in the last phase (8-16 years after the onset of screening) of a long-term (16 years or nine rounds) biennial screening. Whatever the design of the period of ongoing FOBT, CRC incidence neither decreased nor increased, although it was reduced for 5-7 years after the 10-year screening period. Neither the design nor the clinical or demographic parameters of these trials were independently associated with CRC mortality reduction. CONCLUSION: Biennial FOBT decreased CRC mortality by 14% when performed over 10 years, without evidence-based benefit on CRC mortality when performed over a longer period. No independent predictors of CRC mortality reduction have been identified in order to allow a CRC screening programme in any subgroups of subjects at risk.     

The Norwegian Colorectal Cancer Prevention (NORCCAP) Screening Study

Background: Randomized controlled trials of sufficient power testing the long-term effect of screening for colorectal neoplasia only exist for faecal occult blood testing (FOBT). There is indirect evidence that flexible sigmoidoscopy (FS) may have a greater yield. The aim of this study was to determine the diagnostic yield of screening with FS or a combination of FS and FOBT in an average-risk population in an urban and combined urban and rural population in Norway. Methods: 20,780 men and women (1:1), aged 50-64 years, were invited for once-only screening (FS only or a combination of FS and FOBT (1:1)) by randomization from the population registry. A positive FS was defined as a finding of any neoplasia or any polyp &#83 10 &#114 mm. A positive FS or FOBT qualified for colonoscopy. Results: Overall attendance was 65%. Forty-one (0.3%) cases of CRC were detected. Any adenoma was found in 2208 (17%) participants and 545 (4.2%) had high-risk adenomas. There was no difference in diagnostic yield between the FS and the FS and FOBT group regarding CRC or high-risk adenoma. Work-up load comprised 2821 colonoscopies in 2524 (20%) screenees and 10% of screenees were recommended later colonoscopy surveillance. There were no severe complications at FS, but six perforations after therapeutic colonoscopy (1:336). Conclusions: The present study bodes well for future management of a national screening programme, provided that follow-up results reflect adequate proof of a net benefit. It is highly questionable whether the addition of once-only FOBT to FS will contribute to this effect.