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BACKGROUND: The Tianjin Colorectal Cancer (CRC) Screening Program uses a questionnaire (HRFQ) to determine risk status and the initial screening test: stool testing (FIT) for average-risk and colonoscopy for high-risk individuals. AIMS: To determine agreement between colonoscopy-detected CRC and pathology-confirmed CRC. METHODS: A retrospective cohort study was conducted using the data from the 2012 Tianjin CRC Screening Program in Tianjin, China. Participants were aged 60 to 74 and residents of Tianjin who completed both the HRFQ and colonoscopy. Demographics and clinical data were obtained as well as FIT, colonoscopy and pathology results. Cohen’s Kappa was used to determine agreement between colonoscopy-detected and pathology-confirmed CRC. RESULTS: In 2012, 19,096 individuals completed the HRFQ and colonoscopy, of which 10,907 (57.1%) were HRFQ positive and 7,986 (41.8%) were colonoscopy positive. Colonoscopy positive findings included 7160 polyps, 728 adenomas and 102 CRC. Of all colonoscopy positive findings, 1,256 (15.7%) were sent to pathology where 326 were confirmed CRC. Only 59 (18.1%) of the pathology-confirmed CRC were detected at colonoscopy. Agreement between CRC detected at colonoscopy and CRC confirmed by pathology was Kappa=0.22 (95%CI=0.16–0.27). CONCLUSIONS: Poor agreement was found between colonoscopy-detected and pathology-confirmed CRC, suggesting that many CRCs are undetected and untreated. Effectiveness of the screening program would be improved by sending all removed tissues to pathology. FUNDING AGENCIES: Fonds de recherche du Québec- Santé