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The best screening test is the one that gets followed up on

Gastroenterology

Editorial arguing that follow-up adherence is the critical determinant of colorectal cancer screening effectiveness. Published in Gastroenterology.

The Best Screening Test is the One That Gets Followed-up on

Gastroenterology

February 2026 DOI: 10.1053/j.gastro.2026.02.013

van den Berg, D.M.N., Brück, C.C., Nascimento de Lima, P., Alarid-Escudero, F., Hahn, A.I., Lansdorp-Vogelaar, I., & Colorectal Working Group of CISNET [incl. Roa, J.]

Caravaggio — The Incredulity of Saint Thomas (1601) Sanssouci Picture Gallery · Potsdam Thomas presses his finger into the wound to verify what he doubts — not out of defiance, but out of the need to know. A meditation on empirical conviction: belief deferred until the evidence is personally confirmed.

The Problem

Colorectal cancer screening saves lives, but only when completed. Dr. Sidney Winawer’s saying, “the best test is the test that gets done and done well,” has driven campaigns to boost uptake. Yet nearly half of patients with a positive stool-based test never complete the follow-up colonoscopy, and without that step, screening delivers zero benefit while patients bear only the costs and harms.

The Approach

Using the MISCAN-Colon microsimulation model, we simulated 10 million people offered one-time FIT screening at age 45, varying screening and follow-up colonoscopy adherence across five levels (0–100%) to quantify each step’s contribution to life years gained, alongside a review of clinical evidence and system-level barriers.

What We Found

44% Lost to follow-up after a positive stool test

7× Higher CRC death risk without timely follow-up

0% Benefit with zero follow-up regardless of screening uptake

Follow-up adherence is at least as important as screening adherence. 0% follow-up yielded zero life years gained even at 100% screening uptake; 25% screening with 75% follow-up matched 75% screening with 25% follow-up. In safety-net systems, where follow-up runs below 45%, even blood-based screening tests weren’t cost-effective versus no screening.

Life years gained per 1,000 screened at age 45 (FIT vs no screening), across screening and follow-up adherence levels.

Why It Matters

The CRC screening pipeline is leaking. Without timely follow-up colonoscopies, even perfect screening uptake and high-quality tests deliver no benefit. Patient navigation, reminder systems, care coordination, and rideshare programs can close that gap. As NCQA develops new HEDIS measures for follow-up adherence, the message must shift: screening is complete only when appropriate follow-up is provided.

Cite This Work

Cite this work

van den Berg, D.M.N., Brück, C.C., Nascimento de Lima, P., Alarid-Escudero, F., Hahn, A.I., Lansdorp-Vogelaar, I., & Colorectal Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET) [incl. Roa, J.]. (2026). The best screening test is the one that gets followed up on. Gastroenterology. https://doi.org/10.1053/j.gastro.2026.02.013

@article{vandenberg2026gastro,
  author  = {van den Berg, D.M.N. and Brück, C.C. and Nascimento de Lima, P. and Alarid-Escudero, F. and Hahn, A.I. and Lansdorp-Vogelaar, I. and Colorectal Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET) [incl. Roa, J.]},
  title   = {The Best Screening Test Is the One That Gets Followed up On},
  journal = {Gastroenterology},
  year    = {2026},
  doi     = {10.1053/j.gastro.2026.02.013},
  url     = {https://jorgeroac.com/publications/papers/peer-reviewed/gastro-screening-followup/}
}

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