Comparative evaluation of questionnaire-based risk assessment and fecal immunochemical test for colorectal cancer screening

BACKGROUNDThe high-risk factor questionnaire (HRFQ) and fecal immunochemical test (FIT) are widely used in community-based colorectal cancer (CRC) screening.However, the characteristics of individuals identified through different screening strategies, their colonoscopy adherence, and diagnostic outcomes remain poorly characterized in realworld settings.AIM To compare screening positivity, colonoscopy compliance, and diagnostic yield among different CRC screening approaches.METHODS This retrospective cross-sectional study was based on a CRC screening program conducted among residents aged 40-74 years in Guangzhou, Guangdong Province, China between 2022 and 2024.Participants underwent screening with both the HRFQ and FIT.Individuals with a positive result on either test were classified as screen-positive and referred for colonoscopy.Multivariable logistic regression was used to identify factors associated with screening positivity and colonoscopy adherence.The detection rate of target lesions (advanced adenomas or early-stage CRC) was compared between the only HRFQ+ and only FIT+ groups among participants who completed colonoscopy, to assess the diagnostic yield of the two screening approaches. RESULTSAmong 24321 participants, 7117 (29.3%) were screen-positive.Of the screen-positive participants, 5698 (80.1%) were only HRFQ+, 1044 (14.7%) were only FIT+, and 375 (5.3%) were positive for both HRFQ and FIT.Only HRFQ+ was associated with a broader range 4 / 32 of sociodemographic and lifestyle factors than only FIT+.22.1% (1571/7117) of positive screeners received diagnostic colonoscopy.Only FIT+ participants were more likely to complete colonoscopy than those identified by HRFQ alone (adjusted odds ratio: 1.45, 95% confidence interval: 1.24-1.69,P < 0.001).Target lesions were detected in 107 (6.8%) of 1571 colonoscopies among participants who completed colonoscopy.The detection rate of target lesions was more than three times higher in only FIT+ participants (13.7%) than in only HRFQ+ participants (4.5%), whereas the early diagnosis rate did not differ significantly between the groups (P = 0.54). CONCLUSIONThe FIT identified a population with a higher observed yield of clinically relevant lesions and higher colonoscopy adherence, whereas the HRFQ identified a broader high-risk population.These findings suggest complementary roles of the two screening approaches in community-based CRC screening.