• Maaike Buskermolen, Dayna R Cenin, Lise M Helsingen, Gordon Guyatt, Per Olav Vandvik, Ulrike Haug, Michael Bretthauer, and Iris Lansdorp-Vogelaar.
• Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, the Netherlands m.buskermolen@erasmusmc.nl.
• BMJ. 2019 Oct 2; 367: l5383.

ObjectiveTo estimate benefits and harms of different colorectal cancer screening strategies, stratified by (baseline) 15-year colorectal cancer risk.DesignMicrosimulation modelling study using MIcrosimulation SCreening ANalysis-Colon (MISCAN-Colon).SettingA parallel guideline committee (BMJ Rapid Recommendations) defined the time frame and screening interventions, including selection of outcome measures.PopulationNorwegian men and women aged 50-79 years with varying 15-year colorectal cancer risk (1-7%).ComparisonsFour screening strategies were compared with no screening: biennial or annual faecal immunochemical test (FIT) or single sigmoidoscopy or colonoscopy at 100% adherence.Main Outcome MeasuresColorectal cancer mortality and incidence, burdens, and harms over 15 years of follow-up. The certainty of the evidence was assessed using the GRADE approach.ResultsOver 15 years of follow-up, screening individuals aged 50-79 at 3% risk of colorectal cancer with annual FIT or single colonoscopy reduced colorectal cancer mortality by 6 per 1000 individuals. Single sigmoidoscopy and biennial FIT reduced it by 5 per 1000 individuals. Colonoscopy, sigmoidoscopy, and annual FIT reduced colorectal cancer incidence by 10, 8, and 4 per 1000 individuals, respectively. The estimated incidence reduction for biennial FIT was 1 per 1000 individuals. Serious harms were estimated to be between 3 per 1000 (biennial FIT) and 5 per 1000 individuals (colonoscopy); harms increased with older age. The absolute benefits of screening increased with increasing colorectal cancer risk, while harms were less affected by baseline risk. Results were sensitive to the setting defined by the guideline panel. Because of uncertainty associated with modelling assumptions, we applied a GRADE rating of low certainty evidence to all estimates.ConclusionsOver a 15 year period, all screening strategies may reduce colorectal cancer mortality to a similar extent. Colonoscopy and sigmoidoscopy may also reduce colorectal cancer incidence, while FIT shows a smaller incidence reduction. Harms are rare and of similar magnitude for all screening strategies.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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