Roughly half of patients with an abnormal stool-based colorectal cancer screening result never complete the follow-up colonoscopy. For years, that statistic has been framed primarily as a public health problem.
Simon Mathews, MD, a gastroenterologist in rural Pennsylvania, believes it is also an operational one. He argues that too many healthcare organizations treat the follow-up colonoscopy as someone else’s responsibility. The result is a breakdown that leaves patients without potentially lifesaving care and creates avoidable inefficiencies throughout the system.
“This is a real, meaningful clinical gap that we, as all GIs, should be trying to tackle,” Dr. Mathews said. “This is our wheelhouse, and we have the ability to do that.”
A 2023 analysis published in JAMA Network Open examined 32,769 patients across 39 healthcare organizations and found that only 56% completed a colonoscopy within one year of a positive fecal immunochemical test or multitarget stool DNA test. Completion rates ranged from 17% to 72% across organizations. Only one of the 39 systems formally tracked the measure.
For Dr. Mathews, the variation highlights a larger issue. The challenge is not screening. The challenge is what happens next.
Why these patients matter
The patients who fail to complete follow-up colonoscopy are not a random group. They represent some of the highest-risk patients in colorectal cancer screening. A meta-analysis involving more than 6 million average-risk patients found that 5.1% of follow-up colonoscopies after a positive stool test identified colorectal cancer. More than one-quarter detected advanced adenomas.
A 2022 meta-analysis in Gastrointestinal Endoscopy found the pooled adenoma detection rate for colonoscopies following a positive FIT was 47.8%, compared with typical screening colonoscopy ADR benchmarks of 30% to 35%.
“These are the patients who need it the most,” Dr. Mathews said. They are also among the patients most likely to require intervention, whether that involves biopsy, polypectomy, endoscopic mucosal resection or additional surveillance. Yet despite the elevated risk profile, many never reach the procedure room.
Where the system breaks down
According to Dr. Mathews, most failures occur long before a patient reaches an ASC. The first breakdown is navigation. Many stool-based screening programs operate through mailed testing pathways with unclear ownership of follow-up care. Positive results often arrive in already-overloaded primary care inboxes with no automated scheduling process and no standardized outreach mechanism.
“Our modern healthcare system does not make this easy,” Dr. Mathews said. “This is the inbox. It’s 5 million messages a day that we’re trying to sift through.”
“There needs to be a process in place once there are actionable results,” he added. “Right now, there’s just way too much noise in terms of what comes into an inbox that you sometimes lose the actual signal.”
The second challenge is access. And in Dr. Mathews’ view, it receives far less attention than it deserves. Approximately 60% of U.S. counties have no practicing gastroenterologist. Roughly 42 million Americans live in counties with one or fewer GI specialists. A 2021 study of Los Angeles County safety-net patients published in Clinical and Translational Gastroenterology found the likelihood of completing a follow-up colonoscopy fell with each additional kilometer a patient had to travel.
“The further away you are from an actual place where you can get an endoscopy, the outcomes are potentially worse,” Dr. Mathews said. The burden falls disproportionately on rural communities, where colorectal cancer mortality rates remain higher and screening rates remain lower than in metropolitan areas.
Why ownership matters
Dr. Mathews believes healthcare organizations often view the follow-up colonoscopy as the final step in a screening process. He argues they should view it as part of a continuum.
The organizations that perform the procedure have a vested interest in ensuring patients successfully navigate the journey from screening to diagnosis and, when necessary, treatment. That requires more than simply making appointments available. It requires ownership.
A successful process includes clear responsibility for every ordered test, automated identification of positive results, structured patient outreach and realistic scheduling timelines. “There needs to be an endpoint that is reasonable and realistic,” Dr. Mathews said. “It can’t be that there’s a positive test, and it’s going to take six months or longer to get you on the hospital or ASC list. A lot can happen in six months.” The process also extends beyond the procedure itself.
Pathology findings determine future surveillance intervals, which may range from one year to ten years depending on what is discovered. Those recommendations must also be tracked and acted upon.
“We can’t work on closing one loop while creating another that never gets closed,” Dr. Mathews said.
The opportunity ahead
A 2025 randomized trial in Annals of Internal Medicine found that telephone-based patient navigation moved follow-up colonoscopy completion at 12 months from 42.1% in usual care to 55.1% in the intervention arm, in a federally qualified health center population.
For Dr. Mathews, the lesson is straightforward. The organizations that succeed will not be the ones that simply perform colonoscopies. They will be the ones that actively manage the patient journey leading up to them. “This is a patient population that ASCs should take ownership of,” Dr. Mathews said. “It aligns directly with our clinical mission as gastroenterologists, but it also makes sense from an operational standpoint.”
“It’s not enough to be just that endpoint destination,” he added. “It’s worth being invested and involved in the entire process that gets the patient there, and then ultimately gets the patient back home.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.