Colorectal cancer screening in Singapore: progress, challenges and promise

INTRODUCTION March is Colorectal Cancer (CRC) Awareness Month, an annual observance in Singapore and globally that spotlights one of the most common and lethal malignancies. Locally, CRC is the second most common cancer among men and women, after prostate cancer and breast cancer, respectively.[1] Between 2019 and 2023, the age-standardised incidence rates of CRC were 37.3 per 100,000 for men and 26.6 per 100,000 for women, accounting for 14.8% and 15.9% of cancer-related deaths in men and women, respectively. Despite modern endoscopic technology, advances in systemic therapy and perioperative care, population-level outcomes in CRC are driven predominantly by the stage at diagnosis. Therein lies the value of screening, not only as an early detection strategy, but also as a true cancer prevention programme via the identification and removal of premalignant colonic lesions. This commentary reviews the historical development, progress, challenges and future directions of Singapore’s CRC screening programme, with relevance to both clinicians and policymakers. PROGRESS Since the early 2000s, CRC screening has been encouraged by the Singapore Cancer Society via large-scale, voluntary initiatives, including the distribution of free faecal occult blood test kits. In 2011, the Health Promotion Board (HPB) launched a national population-based screening programme for individuals aged ≥ 50 years, using the faecal immunochemical test (FIT) as the primary screening tool, and this was later consolidated under the Screen for Life framework (now renamed Healthier SG Screening). Thus, HPB became the primary facilitator in population-level screening, shifting the approach from passive detection or opportunistic screening to an organised system. Over time, the programme expanded across primary care, to both polyclinics and general practitioner clinics, improving geographic and socioeconomic access. In line with the Healthier SG initiative, CRC screening is positioned as part of a broader preventive health strategy rather than an isolated gastrointestinal initiative. Both colonoscopy and FIT are highly recommended for CRC screening in average-risk adults by major international guidelines. While colonoscopy has the highest sensitivity for both cancer and advanced adenomas, allows for polypectomy, and is performed every 10 years, it is invasive and has lower participation rates. In contrast, FIT is non-invasive, cost-effective and has higher participation rates, but requires annual or biennial testing and has lower sensitivity for advanced adenomas. Recent randomised trials and meta-analyses indicate that FIT is non-inferior to colonoscopy in reducing CRC mortality at 10 years, supporting its use as an effective alternative, especially in organised screening programmes or populations with lower colonoscopy uptake.[2,3] In Singapore, annual FIT-based screening is the recommended cost-effective approach.[4,5] Several indicators suggest that Singapore’s CRC screening programme has made meaningful progress. First, screening participation rate has increased steadily since the introduction of national subsidies and organised outreach, although absolute uptake remains below optimal levels.[6] Second, there has been a stage shift to earlier-stage CRC, potentially improving resectability and survival.[1] The increasing adoption of minimally invasive CRC resection, including endoscopic, laparoscopic and robotic approaches, has contributed to improved perioperative outcomes, shorter hospital stays and faster functional recovery, particularly when cancers are diagnosed at an earlier stage.[7] In addition, while CRC incidence has stabilised in recent decades, mortality rates continue to decline. Globally, factors contributing to the reduction in mortality rate include expansion and improvement of screening programmes, advances in treatments and management, improved health system infrastructure, and public health interventions to reduce modifiable risk factors such as cigarette smoking and alcohol consumption. At the system level, the consolidated oversight under HPB has strengthened programme governance, enabling strong integration between primary care and public hospitals’ endoscopy services, and ensuring consistent quality standards via periodic audits. CHALLENGES Despite a highly developed healthcare system, Singapore’s CRC screening programme continues to be hampered by multiple challenges, including participation, capacity and clinical limitations. Participation and adherence A higher screening participation rate directly reduces mortality and improves cost-effectiveness. Screening programmes should aim for participation rates above 70%–80% to achieve population impact. Despite subsidies, Singapore’s CRC screening participation remains suboptimal, with only 44.9% of Singapore residents aged 50–74 years having undergone colorectal screening within the recommended screening frequency in 2024.[6] Lower participation rates have been observed in certain ethnic minorities and individuals with lower socioeconomic status or education level. Health education, competing work responsibilities, language barriers and limited engagement with preventive care services contribute to differential uptake. Without deliberate, targeted interventions, the inequities would disproportionately benefit those who are more health-literate and socioeconomically advantaged, thereby reducing the overall effectiveness of the programme and exacerbating health outcome disparities. Misconceptions about stool testing, fear of colonoscopy and low perceived personal risk continue to impede participation and subsequent adherence to follow-up colonoscopy among those with a positive test. This underscores the importance of primary care engagement and physician recommendation, which remains one of the strongest predictors of screening uptake.[8,9] However, primary care doctors may have limited consultation time to explain the benefits, options and pathways of CRC screening. There may also be variable familiarity with evolving screening and polyp surveillance guidelines, and inconsistent follow-up of patients who decline initial screening. System capacity and timeliness As FIT uptake increases, ensuring timely colonoscopy after a positive FIT is critical, as delays may erode the mortality benefit of screening. Many public healthcare institutions face challenges in manpower constraints and endoscopy suite capacity, with competing needs for various clinical indications, leading to inter-institutional variability in waiting times. Through workforce design and prioritisation, hospitals are sustaining improvements to achieve time-to-colonoscopy benchmarks. In parallel, there is increasing interest in earlier initiation of CRC screening, as emerging data suggest a rising incidence among younger adults. Consideration of earlier screening would need to be carefully evaluated in the local context, leveraging population-level data and cancer registry trends while balancing potential gains in early detection against resource implications.[10] Clinical limitations Faecal immunochemical test has limited sensitivity for certain colonic lesions, including right-sided and flat lesions, and interval cancers continue to occur.[11] There should be careful patient counselling and vigilance for symptoms even after a negative FIT. In addition, although post-polypectomy surveillance recommendations are established, adherence is variable, leading to concerns about over- or under-surveillance.[12] While under-surveillance may lead to missed opportunities to detect cancer, over-surveillance can crowd out screening colonoscopies for FIT-positive individuals, thereby reducing overall programme efficiency. PROMISE Notwithstanding these challenges, the next phase of Singapore’s CRC screening programme holds significant promise, particularly in three inter-related domains: improving participation, leveraging technology and innovation, and advancing data integration towards a learning health system. Improving participation Improving participation rate remains a crucial and powerful lever to reduce CRC mortality. Although cost is a factor, behavioural and perceptual barriers, including low perceived risk and competing priorities, are stronger drivers in non-participation. Future interventions could thus focus on addressing these barriers, such as simplifying access (mailing of FIT kits, community kiosks, electronic ordering of FIT), tracking of kit return, automated reminders, strong primary care endorsement and engagement, and targeted educational campaigns. Singapore’s mature national health IT ecosystem serves as an enabler for integration across primary care, laboratories and specialist services, reducing administrative friction and loss to follow-up. Technology and innovation Artificial intelligence (AI)-assisted colonoscopy has shown improvements in adenoma detection rate across multiple randomised trials and meta-analyses,[13] with the potential to reduce operator variability and interval cancer. As screening volume grows, AI may serve as a quality equaliser across and within institutions. However, further evaluation of real-world effectiveness, cost implications and workflow integration is needed. Beyond polyp detection, AI—particularly large language models—has demonstrated high potential and accuracy in automatic polyp surveillance recommendation by interpreting endoscopy and pathology reports. Singapore’s opportunity lies in embedding innovation within a learning health system, ensuring that technological advances are equitable and translate into effective, sustainable gains in CRC prevention. Data integration and learning health system Singapore’s healthcare ecosystem is supported by the national electronic health record system, a major asset in supporting a learning health system, where data, technology and science are used to improve patient care continuously in real-time. By linking screening records, laboratory results, endoscopy findings, pathology and cancer registry outcomes within an established data governance framework, this system allows for programme performance surveillance, early identification of issues and the conduct of pragmatic research. CONCLUSION As we reflect on Singapore’s journey in CRC screening this month, we appreciate the achievements thus far. Yet, the ultimate success of our CRC screening programme will rely less on technological advances than on human factors: trust, participation and timely follow-through. With continued innovation and sustained engagement, Singapore is well-positioned to realise the full promise of population-based CRC prevention. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.