Nearly Half of Patients Miss Colonoscopy Even After Positive Stool Test: JAMA
Singapore: A review of nearly 20,000 patients found that reminders, patient support, and better referral systems helped more people complete colonoscopy after an abnormal colorectal cancer screening test.
A positive stool test for colorectal cancer is not a diagnosis of cancer, but it is a finding that requires further investigation. Yet many patients who undergo screening never complete the recommended colonoscopy. Some are unaware of its importance, others face financial or logistical difficulties, and some are lost during the referral process. A new study published in JAMA Internal Medicine suggests that simple changes in how hospitals and physicians follow up these patients can substantially improve completion rates.
Published online on October 5, 2026, the systematic review and meta-analysis examined which interventions were most effective in ensuring that patients underwent colonoscopy after an abnormal faecal immunochemical test (FIT) or faecal occult blood test (FOBT).
Researchers led by Wei Yu Chua reviewed 21 studies involving 19,613 patients aged 50–75 years. The studies included randomised trials and non-randomised interventions designed to improve follow-up after an abnormal stool screening result.
The findings revealed a substantial gap between identifying an abnormal result and completing the necessary investigation.
Across the included studies, the pooled proportion of patients completing colonoscopy was 47.8% in control groups compared with 69.1% in groups receiving follow-up interventions.
Several approaches were associated with better completion rates.
Patient navigation, in which designated staff help patients understand the result, arrange appointments, and overcome barriers to care, was associated with a 24% higher likelihood of colonoscopy completion (risk ratio [RR], 1.24; 95% CI, 1.15–1.33).
Reminders sent directly to patients were associated with a 32% relative improvement (RR, 1.32), while reminders to clinicians were associated with a 36% improvement (RR, 1.36).
Automated referrals for gastroenterology consultation showed an even larger association, with a risk ratio of 1.68. However, the findings for this approach varied considerably between studies, making the precise benefit less certain.
These results highlight an often overlooked problem in preventive medicine. Screening programmes are commonly evaluated by the number of people tested, but an abnormal result that is not investigated may leave an important opportunity for early diagnosis unrealised.
FIT detects small amounts of blood in stool and is widely used for colorectal cancer screening. Although a positive result can occur for reasons other than cancer, colonoscopy is needed to identify possible colorectal malignancy or precancerous lesions.
Repeating the stool test instead of arranging colonoscopy is not an appropriate substitute for diagnostic evaluation after a positive screening result. A subsequent negative FIT does not reliably exclude the abnormality responsible for the earlier result.
The study also suggests that improving follow-up does not necessarily require expensive technology. Telephone calls, text reminders, clear communication and assistance with scheduling may help patients complete the recommended investigation.
However, the findings should not be interpreted as proof that every intervention will work equally well in every healthcare setting. The included studies differed in design, patient populations and follow-up arrangements, with considerable variation in several pooled estimates.
The analysis measured colonoscopy completion rather than cancer mortality or long-term patient outcomes. It therefore demonstrates improvement in an important step of the screening pathway, not a directly established reduction in cancer deaths.
For physicians, the practical implications are straightforward. Every positive FIT or FOBT should trigger a documented plan for diagnostic colonoscopy, with responsibility assigned for communicating the result, arranging referral and confirming completion.
Hospitals and screening centres should maintain a register of patients with abnormal stool tests and actively follow up those who have not completed colonoscopy. Particular attention may be needed for patients facing financial, transport or appointment-related difficulties.
The findings are relevant to India, where patients may undergo screening at one facility and seek further care elsewhere, increasing the possibility that abnormal results remain unresolved.
The study reinforces an important clinical principle: colorectal cancer screening does not end when the laboratory report is issued. For patients with a positive stool test, arranging and completing diagnostic colonoscopy is the essential next step. A reliable follow-up system may be as important as the screening test itself.
Original Research Reference
Chua WY, Chew LX, Chan CKM, et al. Evaluation of Intervention Strategies to Improve Follow-Up Colonoscopy After Abnormal FIT/FOBT Result: A Systematic Review and Meta-Analysis. JAMA Internal Medicine. Published online October 5, 2026. DOI: https://doi.org/10.1001/jamainternmed.2026.4827
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