PURPOSE The Malaysian Ministry of Health had launched free opportunistic screening for colorectal cancer using immunochemical fecal occult blood test (iFOBT) targeting the average-risk individuals since 2014. This study aims to determine factors associated with colorectal cancer screening using iFOBT among the average-risk Malaysian population. METHODS A cross-sectional study was conducted at five government-run health clinics in the state of Selangor. Adults with an average risk of colorectal cancer (age > 50 years, asymptomatic, and no family history of colorectal cancer) were recruited using systematic random sampling. An interviewer-administered questionnaire adapted from the Cancer Awareness Measure and Health Belief Model was used. RESULTS The median age of participants was 61 years (interquartile range, 56 to 66). Almost 60% of participants indicated their willingness to be screened. However, only 7.5% had undergone iFOBT. Good knowledge of risk factors of colorectal cancer, perceived susceptibility to the disease, and the doctor's recommendation were associated with increased willingness to be screened: adjusted odds ratio (aOR), 1.66 (95% CI, 1.12 to 2.46); aOR, 1.70 (95% CI, 1.08 to 2.70); and aOR, 5.76 (95% CI, 2.13 to 15.57), respectively. Nevertheless, being elderly (aOR, 0.67; 95% CI, 0.45 to 0.99) and high negative perception toward the testing method (iFOBT) (aOR, 0.12; 95% CI, 0.05 to 0.30) were independently associated with lower willingness to be screened. Multivariable analysis within the average-risk individuals who were willing to be screened for colorectal cancer showed that the doctor’s recommendations remained as an important cue for positive action, whereas negative perception toward the test was a significant barrier to the actual uptake of iFOBT. CONCLUSION The present findings must be factored in when tailoring colorectal cancer screening promotion activities in multiethnic, middle-income settings.

Colorectal cancer is not only one of the most common, but also one of the most preventable cancers globally. Screening for colorectal cancer has been associated with reduced diseasespecific mortality through detection of cancer at earlier stages, as well as through detection and removal of its precursor lesions.While most professional guidelines recommend routine screening of asymptomatic adults older than 50 years for colorectal cancer, there is disagreement on the age to stop screening. For example, the US Preventive Services Task Force (USPSTF) and the American College of Gastroenterology recommend screening until age 75 years, followed by individualized decision-making for people older than 75 years. 1,2 In contrast, the Canadian Task Force on Preventive Health does not recommend screening adults 75 years and older for colorectal cancer. 3 Likewise, the Asia Pacific Colorectal Cancer Working Group recommends 75 years as a reasonable age limit to stop screening. 4 Nonetheless, these recommendations were largely made based on evidence from modeling studies 5 and indirect evidence, such as reduced life expectancy in older individuals, and disparate inclusion of older adults in colorectal cancer screening trials. 3 Amid the scant empirical data on when best to stop offering colorectal cancer screening, in this issue of JAMA Oncology, Ma et al 6 examine the association between lower endoscopy (colonoscopy and sigmoidoscopy) and the risk of colorectal cancer, as well as its mortality in older adults (older than 75 years). By performing a robust analysis of data from 2 large prospective cohort studies, the Nurses' Health Study and the Health Professionals Follow-up Study, the authors have demonstrated that irrespective of prior endoscopic screening history, screening via colonoscopy or sigmoidoscopy after age 75 years was associated with significantly lower incidence of colorectal cancer (multivariable hazard ratio [HR], 0.61; 95% CI, 0.51-0.74) and colorectal cancer-related mortality (HR, 0.60; 95% CI, 0.46-0.78). It was also reported that no survival benefit was observed with screening endoscopy after age 75 years in participants who had cardiovascular disease (HR, 1.18; 95% CI, 0.59-2.35) or significant comorbidities (HR, 1.17; 95% CI, 0.57-2.43). Therefore, this study appears to address a widely debated topic by providing empirical evidence that points toward a reduction in risk of colorectal cancer, as well as a survival gain associated with screening colonoscopy or sigmoidoscopy in individuals older than 75 years who have no substantial comorbidities, regardless of whether they have undergone prior endoscopic screening.