Virtual colonoscopy continues to show promise as a colorectal cancer screening test and is technically evolving rapidly. It has particular advantages with regard to acceptability by both radiologists and patients. Important steps to achieve implementation include clear delineation of all of the technical components necessary to produce consistent high performance and development of clear-cut recommendations for interpretation and management of polyps of various sizes and the range of extracolonic findings identified. Development of an effective methodology to perform the test without bowel preparation or demonstration of cost-effectiveness for identification and treatment of one or more significant extracolonic diseases would be major breakthroughs, provided they are still accompanied by effective detection of significant colon neoplasms. Issues regarding general effectiveness and cost-effectiveness must be resolved before virtual colonoscopy is endorsed for widespread colorectal cancer screening or utilized for that purpose.