Multiple Negative Fecal Immunochemical Tests Reduce Risk of Advanced Neoplasia in a Colonoscopy Surveillance Program

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Background & Aims: In above-average-risk individuals undergoing colonoscopy-based surveillance for colorectal cancer (CRC), screening with fecal immunochemical tests (FIT) between colonoscopies might facilitate personalization of surveillance intervals. Because a negative FIT is associated with a reduced risk for CRC, we examined the relationship between number of rounds of negative FIT and risk for advanced neoplasia in individuals undergoing surveillance colonoscopy. 

Methods: We conducted a retrospective cohort study on 4021 surveillance intervals in 3369 individuals (50–74 years), who had completed a 2-sample FIT between colonoscopies, from 1 to 4 rounds at 1–2 yearly intervals, each with a negative result (<20 μg hemoglobin/g feces). Incidence of advanced neoplasia (CRC or advanced adenoma) was determined at the follow-up colonoscopy. Competing-risk regression was used to assess the association between multiple negative FIT results and the risk of advanced neoplasia within 2 years. 

Results: The incidence of advanced neoplasia in the cohort was 9.9% and decreased with increasing numbers of rounds of negative FIT results: 11.1% after 1 negative FIT to 5.7% after 4 negative FIT. The risk of advanced neoplasia was significantly lower in participants with 3 (subdistribution hazard ratio, 0.50; 95% confidence interval, 0.24–0.97) and 4 (subdistribution hazard ratio, 0.33; 95% confidence interval, 0.15–0.73) rounds of negative FIT compared with only 1 negative FIT. 

Conclusions: There was a low risk of advanced neoplasia after multiple rounds of negative FIT in above-average-risk people undergoing surveillance with no neoplasia or nonadvanced adenoma at prior colonoscopy. This supports the use of interval FIT to personalize surveillance by lengthening colonoscopy intervals following multiple negative FIT results.

Original languageEnglish
Pages (from-to)2389-2398.e2
Number of pages12
JournalClinical Gastroenterology and Hepatology
Issue number9
Early online date5 Jan 2023
Publication statusPublished - Aug 2023


  • Colonoscopy
  • Colorectal Neoplasia
  • CRC
  • Fecal Immunochemical Test
  • Screening


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