Changing Colorectal Cancer Epidemiology Demands a Risk-Adapted European Screening Strategy

European colorectal cancer screening remains largely age-defined despite changing epidemiology, heterogeneous risk, non-participation and finite colonoscopy capacity. European guidance already anticipates risk-based thresholds, intervals and test allocation; how to test these across heterogeneous health systems remains unresolved. We propose a four-decision policy and research framework, not a validated clinical protocol, addressing when screening should begin or recur, which first-line test should be offered, what result or risk trajectory should trigger escalation, and how diagnosis and treatment should be completed. Quantitative faecal immunochemical testing (FIT) should remain a principal population-based strategy and high-quality colonoscopy the confirmatory and therapeutic standard, while national programmes may differ. Previous quantitative FIT results, age, sex, family history, comorbidity and screening behaviour can be prospectively evaluated as modifiers of interval and threshold. Multitarget stool tests, blood-based cell-free DNA, microbiome or volatile-organic-compound classifiers, colon capsule endoscopy and CT colonography should address defined pathway failures rather than act as interchangeable competitors. Because evidence for risk adaptation remains modelled or observational, implementation should proceed only through prospectively governed pilots. Evaluation should prioritise sustained participation, advanced neoplasia removed, interval cancer, colonoscopy use, equity and societal cost. Risk adaptation should optimise existing workflows through prospectively validated programmatic rules, not unvetted diagnostic layers.