Sustainable infrastructure and risk stratification are needed to appropriately deliver colorectal cancer screening globally

In their article in this issue, Selmouni and colleagues report on the feasibility, acceptability, and implementation challenges of delivering an opportunistic colorectal cancer screening program that offers fecal immunochemical testing (FIT) as part of routine primary care in Morocco. The study consented and enrolled nearly 10,000 patients from 10 primary care clinics in 2 Moroccan provinces. Of the 9908 individuals aged 50 to 75 years who completed an FIT, 73.3% were women, 460 (4.7%) had an abnormal test result, and 288 (62.6% of those with an abnormal test) completed a followup colonoscopy. Among those who completed colonoscopy, 98 (34.0%) had an adenoma, and 43 (14.9%) had advanced neoplasia (an adenoma with advanced histology, a polyp ≥10 mm, or cancer). This yield is relatively low compared with what was typically reported in prior research from other countries. 4 Selmouni and colleagues note that populationbased FIT programs have been successful in lowering mortality from colorectal cancer in several regions of the world; participants in an FITbased colorectal cancer screening program in Europe, for example, had a nearly 40% lower risk of dying from colorectal cancer than nonparticipants. However, because of the challenges documented in that study, including inadequate enrollment of men, relatively low rates of followup colonoscopy, and the amount of time and effort necessary to implement the program, the authors conclude that Morocco should prioritize primary prevention (eg, diet, exercise, tobacco use) and early diagnosis of colorectal cancer through early symptom detection over opportunistic screening programs like the one they studied or should establish a pragmatic and locally validated riskbased approach to optimize the costeffectiveness of colorectal cancer screening. The article by Selmouni et al speaks to 2 important facts about colorectal cancer screening programs. First, a successful colorectal cancer screening program requires a sustainable infrastructure to ensure that those who receive an abnormal test result on initial stoolbased testing can successfully obtain a followup colonoscopy. Second, the authors’ conclusions highlight the potential promise of riskstratified approaches for optimizing the yield of colorectal cancer screening programs in many populations and settings and may be critical to program success among populations in which the incidence of colorectal cancer is relatively low. Patients in the study by Selmouni and colleagues were offered a pointofcare test (DIAQUICK FIT; DIALAB GmbH) that produced results in 5 minutes and were provided with counseling and appointment scheduling assistance at the same visit, yet the rate of followup colonoscopy was only 62.6%. Furthermore, both completion rates and wait times for colonoscopy were affected by variations in demand for colonoscopy, indicating that capacity was insufficient to meet demand. These problems also exist in the United States, where rates of followup colonoscopy for patients served by federally qualified health centers range from 18% to 59%, and the median time to colonoscopy typically exceeds national benchmarks. 10 Failure to receive a timely colonoscopy after an abnormal FIT negates the benefits of screening; thus sustainable infrastructure that can ensure sufficient colonoscopy capacity is critical. In addition, programs must actively work to reduce multilevel barriers to screening across the cancer continuum. Given the costs of colonoscopy, establishing sustainable infrastructure for colorectal cancer screening can be expensive. Experts at the International Agency for Research on Cancer have suggested that, for many lowincome and middleincome countries where the risk of colorectal cancer tends to be lower than in highincome countries, the expense of mounting a mass screening effort may not justify the benefit given the significant costs of colonoscopy and the inadequate implementation of diagnostic and treatment services in these countries. The Moroccan agestandardized incidence of colorectal cancer is greater than 3fold lower than that in the United States (Morocco, 12.9 men and 9.9