Why Patients With Positive Bowel Cancer Screening Tests Never Get Their Colonoscopy

Colorectal cancer remains one of the most common and deadly cancers worldwide, yet it is also one of the most preventable when screening works as intended. In Alberta, Canada, the frontline screening tool is the fecal immunochemical test, or FIT, a simple stool-based test that detects hidden blood in the stool, an early warning sign of possible cancer or precancerous polyps. When that test comes back positive, clinical guidelines are unambiguous: the patient should receive a timely follow-up colonoscopy, the procedure that can both detect and remove lesions before they become life-threatening. But a new study from researchers at Cancer Prevention and Screening Innovation, Primary Care Alberta, and the University of Calgary’s Cumming School of Medicine reveals that in practice, many patients with a positive FIT never complete that crucial follow-up, and the reasons stretch far beyond patient reluctance.

The study, published in BMC Health Services Research, took an unusual and much-needed angle. While earlier research has focused heavily on why patients themselves fail to complete colonoscopy after an abnormal screening result, comparatively little attention has been paid to the people who run the screening pipeline: the physicians, nurses, clinic managers, and administrative staff who guide patients from a positive stool test to the endoscopy suite. Understanding their perspective matters because the journey from FIT to colonoscopy is a chain of handoffs involving primary care clinics, central triage systems, hospital endoscopy units, and electronic health records, and a weak link anywhere in that chain can silently drop a patient out of the system.

To capture that perspective, the team conducted a qualitative descriptive study using semi-structured interviews with healthcare providers involved in colonoscopy follow-up across Alberta, a province whose geography ranges from dense urban centers like Calgary and Edmonton to vast rural and remote regions. Participants were purposively recruited, supplemented by snowball sampling in which early interviewees helped identify further relevant colleagues, until seventeen providers had taken part. The interviews were conducted virtually, audio-recorded, transcribed, and then analyzed using a combined inductive and deductive thematic approach, meaning the researchers both allowed new themes to emerge from the data and tested them against established theory.

That theoretical scaffolding is where the study gains much of its analytical power. The researchers mapped their findings onto two widely used implementation science frameworks. At the individual level, they applied the Capability, Opportunity, Motivation–Behaviour model, known as COM-B, together with the Theoretical Domains Framework, which decompose behavior into what people are able to do, what their environment allows them to do, and what drives them to do it. At the health system level, they used the Consolidated Framework for Implementation Research 2.0, or CFIR 2.0, which organizes the structural, cultural, and resource characteristics of health systems that shape whether evidence-based practices actually get delivered. This dual mapping allowed the team to translate messy, real-world accounts into actionable categories that intervention designers can target.

The headline finding is striking in its simplicity: the most important barriers to colonoscopy completion occur before the procedure ever takes place. At the patient level, providers described people who did not fully understand what a positive FIT result meant or what a colonoscopy involved, a knowledge gap that can leave an abnormal result feeling abstract rather than urgent. Fear and anxiety about the procedure itself, from the bowel preparation to the sedation to the possibility of a cancer diagnosis, weighed heavily on some patients. Others faced competing life responsibilities, socio-economic constraints, and practical challenges around transportation, travel distances, and the lack of a friend or family member to accompany them, all of which can make an elective procedure feel impossible to schedule even when the medical stakes are high.

Perhaps more surprising are the barriers that providers located within their own profession and within the health system itself. Some clinicians, the study found, used the FIT inappropriately, for example deploying it in contexts where it is not the right tool, which can muddy the follow-up pathway. Gaps in knowledge about colorectal cancer screening pathways were also reported among providers, meaning some positive results may not be routed to colonoscopy as efficiently as guidelines intend. Clinics had limited resources to support patient follow-up, and the episodic nature of walk-in clinic care posed a particular challenge: when a patient sees a different provider at every visit, no single clinician may feel ownership over ensuring that a positive screening test gets acted upon, and continuity of care, a known driver of preventive care completion, breaks down.

At the system level, the picture grew more complex still. Alberta’s geography creates real inequities, with patients in rural and remote areas facing longer travel for procedures concentrated in urban centers. Referral and triage models varied across the province, so the speed and reliability of the path from positive FIT to booked colonoscopy depended on where a patient lived. The province’s electronic health record system, Connect Care, had limitations that complicated follow-up workflows, and staffing and space constraints limited endoscopy capacity. In some regions, communication gaps between primary care teams and hospital teams meant that information about positive results and completed follow-ups did not always flow smoothly between the parts of the system that needed it.

Yet the study is not simply a catalogue of failures. Providers also identified facilitators that are already working or could be scaled up. System navigation support, in which dedicated staff help patients overcome logistical and informational hurdles, emerged as a key enabler of completion. Patient education, delivered clearly and early, helps transform an alarming result into an understood and actionable one. Reminder systems prompt both patients and clinics to keep follow-up on track. Virtual consultations reduce the burden of travel and time off work, particularly valuable across a province as large as Alberta. And centralized intake and triage models, which route referrals through a coordinated hub rather than leaving each clinic to manage its own pipeline, offer a structural fix for the variability that providers described.

The implications reach well beyond Alberta. Organized screening programs across Canada, the United Kingdom, Australia, and much of Europe rely on stool-based tests as their entry point, and every one of them faces the same downstream challenge: converting abnormal results into completed diagnostic procedures. The Alberta study suggests that programs that measure only screening participation rates may be missing the point where lives are actually saved or lost, in the interval between a positive test and the colonoscopy that follows it. The finding that pre-procedure barriers dominate is a call to redirect quality-improvement energy toward that interval, with interventions that are coordinated across patient, provider, and system levels rather than aimed at a single point of failure.

The multi-level framing is also the study’s central methodological lesson. By anchoring provider accounts in COM-B, the Theoretical Domains Framework, and CFIR 2.0, the researchers demonstrated how implementation science can turn qualitative interviews into a structured map of intervention targets: education and reassurance for patients, knowledge support and follow-up resources for providers, and integrated referral, triage, and communication infrastructure for the system. The authors conclude that addressing these barriers requires coordinated, multi-level, and regionally tailored strategies that strengthen patient education, provider support, and system integration. In a field where a missed colonoscopy can mean a missed opportunity to catch cancer at a curable stage, that conclusion is less an academic abstraction than a practical blueprint, and one that screening programs everywhere would do well to study. The research was funded by Alberta Health, approved by the Health Research Ethics Board of Alberta, and is available open access for clinicians, program designers, and policymakers who want to examine the full detail of what providers on the screening front lines had to say.

Subject of Research: Barriers and facilitators to completing follow-up colonoscopy after a positive fecal immunochemical test in Alberta's colorectal cancer screening program

Article Title: Barriers and facilitators to colonoscopy completion after FIT + in Alberta: a qualitative description of healthcare providers’ perspectives

Article References: Mah, S., Teare, G. F., Campbell, M., & Adhikari, K. (2026). Barriers and facilitators to colonoscopy completion after FIT + in Alberta: a qualitative description of healthcare providers’ perspectives. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15718-1

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15718-1

Keywords: colorectal cancer screening, colonoscopy, fecal immunochemical test, healthcare providers, implementation science, COM-B, Theoretical Domains Framework, CFIR 2.0, health services research, Alberta, patient barriers, centralized triage