Background <p>Colorectal cancer (CRC) remains a major public health burden in Malaysia. Although the national immunochemical faecal occult blood test (iFOBT) screening programme has expanded substantially in recent years, completion of diagnostic colonoscopy following a positive iFOBT result remains persistently low.</p> Objectives <p>This commentary examines the persistent iFOBT-to-colonoscopy gap in Malaysia and proposes an integrated conceptual framework to guide interventions that improve diagnostic follow-up.</p> Discussion <p>National and community-based studies demonstrate increasing iFOBT uptake but consistently suboptimal colonoscopy completion rates despite meaningful detection of colorectal cancer and polyps. Existing evidence suggests that fear, procedural anxiety, financial and logistical barriers, poor awareness, fragmented referral systems, and weak care coordination contribute to attrition along the screening pathway. To address these challenges, this commentary integrates the Health Belief Model (HBM) with the socio-ecological model (SEM) to illustrate how behavioural beliefs are influenced by interpersonal, organisational, community, and policy-level factors. The framework highlights the importance of coordinated interventions including patient navigation, reminder systems, provider engagement, digital referral tracking, community outreach, and public-private collaboration.</p> Conclusion <p>Improving colonoscopy completion after positive iFOBT results requires a coordinated multi-level systems approach that addresses both behavioural and structural barriers to strengthen continuity across the CRC screening continuum.</p>