This prospective cohort study (n=376,511; Stockholm-Gotland, Sweden, 2008–2021) evaluated CRC-specific mortality reduction associated with invitation to and participation in biennial FOBT screening among adults aged 60–69, adjusting for contamination bias (late-diagnosed CRC deaths) and nonadherence.
After bias adjustment, invitation to FOBT screening was associated with a 26% reduction in CRC mortality (RR 0.74; 95% CI, 0.58–0.94); after further adjustment for nonadherence, actual participation was associated with a 43% reduction (RR 0.57; 95% CI, 0.40–0.80).
- The control group was not a pure unexposed group — some received invitations between 2013–2015, requiring additional statistical correction. - Adjustments for contamination and nonadherence relied on modeling assumptions that may introduce uncertainty. - The study population was limited to one Swedish region (60–69 age group), which may limit generalizability to other settings or age ranges.
FOBT screening meaningfully reduces CRC mortality — but the benefit is larger than unadjusted analyses suggest, with participation (vs. mere invitation) nearly doubling the reduction. Clinicians should prioritize strategies that boost actual screening uptake, not just program enrollment.
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