doi:10.1016/S0140-6736(25)00145-XengCastells, AntoniQuintero, EnriqueBujanda, LuisCastán-Cameo, SusanaCubiella, JoaquínDíaz-Tasende, JoséLanas, ÁngelAkiko, OnoSerra-Burriel, MiquelFrías-Arrocha, EladioHernández, CristinaJover, RodrigoAndreu, MontserratCarballo, FernandoMorillas, Juan DiegoSalas, DoloresAlmazán, RaquelAlonso-Abreu, InmaculadaBanales, Jesús M.Hernández, VicentPortillo, IsabelVanaclocha-Espí, MercedesVega, Mariola de laCOLONPREV study investigatorsEffect of invitation to colonoscopy versus faecal immunochemical test screening on colorectal cancer mortality (COLONPREV): a pragmatic, randomised, controlled, non-inferiority trialART-2025-143785Background: Colonoscopy and the faecal immunochemical test are accepted strategies for colorectal cancer screening in the average-risk population (ie, people aged ≥50 years without personal or family history of colorectal cancer). In this trial, we aimed to compare whether invitation to screening with faecal immunochemical test was non-inferior to colonoscopy in a screening programme. Methods: COLONPREV was a pragmatic, randomised, controlled, non-inferiority trial done at 15 tertiary hospitals across eight regions of Spain. Eligible participants were presumptively healthy and aged between 50 years and 69 years without a personal history of colorectal cancer, adenoma or inflammatory bowel disease, family history of hereditary or familial colorectal cancer (ie, two or more first-degree relatives with colorectal cancer or one diagnosed before age 60 years), severe comorbidities, or previous colectomy. Participants were randomly assigned (1:1) to one-time colonoscopy or biennial faecal immunochemical test before invitation to screening. The primary endpoint was colorectal cancer mortality at 10 years, assessed in the intention-to-screen population. An absolute difference of less than 0·16 percentage points was required to show non-inferiority. This trial was registered with ClinicalTrials.gov, NCT00906997. Findings: Between June 1, 2009, and Dec 31, 2021, 57 404 individuals were randomly assigned to receive an invitation for colonoscopy (n=28 708) or the faecal immunochemical test (n=28 696). The intention-to-screen population consisted of 26 332 individuals in the colonoscopy group and 26 719 in the faecal immunochemical test group. In the intention-to-screen population, participation in any form of screening was 31·8% in the colonoscopy group and 39·9% in the faecal immunochemical test group (risk ratio [RR] 0·79 [95% CI 0·77 to 0·82]). Faecal immunochemical testing was non-inferior to colonoscopy with regard to the risk of colorectal cancer mortality at 10 years: the risk was 0·22% (55 deaths) in the colonoscopy group and 0·24% (60 deaths) in the faecal immunochemical test group (risk difference -0·02 [95% CI -0·10 to 0·06; RR 0·92 [95% CI 0·64 to 1·32]; pnon-inferiority=0·0005). Interpretation: Participation in screening was higher among individuals invited to faecal immunochemical test screening than colonoscopy screening. On the basis of participation observed in this study, a faecal immunochemical test-based programme was non-inferior to a colonoscopy-based programme for colorectal cancer-related mortality.2025http://zaguan.unizar.es/record/15365410.1016/S0140-6736(25)00145-Xhttp://zaguan.unizar.es/record/153654oai:zaguan.unizar.es:153654info:eu-repo/grantAgreement/ES/ISCIII/CD22-00087info:eu-repo/grantAgreement/ES/ISCIII/FI22-00203info:eu-repo/grantAgreement/ES/ISCIII/INT22-00009info:eu-repo/grantAgreement/ES/ISCIII/PI08-90717The Lancet 405, 10486 (2025), 1231-1239All rights reservedhttp://www.europeana.eu/rights/rr-f/info:eu-repo/semantics/closedAccess