A study in China followed 5911 individuals after removal of adenoma in national colorectal cancer screening from 2006–2021, of whom 2448 completed the second round (989 by direct colonoscopy, 1459 by FIT test) and 3463 declined. Participants with per-protocol FIT follow-up had a 44% lower risk of colorectal cancer (HR=0.56, 95% CI: 0.31–0.98; p=0.044) compared to those who refused follow-up, with a mean follow-up of 7.79 years. Direct follow-up with colonoscopy reduced the risk by 49% (HR=0.51, 95% CI: 0.27–0.89; p=0.019). Cancer incidence was similar in the FIT-negative (70.38/100,000 person-years) and colonoscopy-positive (80.14/100,000 person-years) versus the colonoscopy group (53.56/100,000 person-years; p=0.8834). Not having a colonoscopy after a positive FIT increased the risk 6.64 times (aIRR=6.64, 95% CI: 1.11–39.83; p=0.038). Risk factors for adenoma recurrence included smoking (aOR=3.72 in current smokers), obesity (aOR=3.21) and advanced adenoma (aOR=3.02), while frequent alcohol drinking reduced it (aOR=0.43). Protocol-based FIT surveillance after adenoma resection was associated with a reduced risk of cancer comparable to colonoscopy, but requires adherence to colonoscopy after a positive test.