The recent paper by Scholefield and colleagues1 on the 20 year follow-up of the ‘Nottingham’ randomised controlled trial of guaiac based faecal occult blood test (gFOBT) colorectal cancer (CRC) screening, reports an intention to screen benefit of 13% reduced mortality from CRC and a participant benefit of 18% reduction, in spite of offering only biennial screening and with only 60% first round participation (see page 1036). Their three ‘impact’ statements are an important basis for progressing screening worldwide using faecal tests.

The first impact statement is that such screening is worthwhile.

Given that several other controlled trials of gFOBT screening show mortality reduction from CRC,2–5 and that such screening is considered not only cost effective but cost saving,6 this cannot be disputed. Indeed, it is more than worthwhile—organised population based screening programmes must be implemented. However, a recent publication reviewing international programmes shows that fully organised screening is still in its infancy in many countries.7 Why then is CRC screening not universally accepted and/or fully implemented?

There are many reasons relating to the population, politics, public health, purse, providers of healthcare and profession. Space limitations preclude a full analysis but this recent paper by Scholefield et al1 provides a platform on which to address some of these.

Their observed impact on CRC mortality of gFOBT screening was small, a reduction of just 13%, regardless …