Intensity of Colorectal Cancer Screening Strategies and the Optimal Policy Choice: A Systematic Review of European Cost Effectiveness Analyses

OBJECTIVES: Colorectal cancer (CRC) screening programmes can be offered at various intensities resulting from variation in the screening age range, interval and Fecal Immunochemical Test (FIT) cut-offs. Screening intensity influences programme cost-effectiveness. This review aims to explore intensities assessed by CRC screening cost-effectiveness analyses (CEAs) in Europe within the context of current policies for average risk populations.

METHODS: We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Web of Science, and Scopus for peer-reviewed original articles on model-based CEAs of CRC screening on average-risk populations in Europe using non-invasive stool-based tests.

RESULTS: Our search retrieved a total of 430 citations, after removing the duplicates and applying the inclusion and exclusion criteria we identified 37 studies. Biennial screening was the most frequently used interval which was analysed in 35 studies. Annual screening was assessed in 13 studies, all of which found it to be optimally cost-effective. There was a wide variation in the screening age range examined by the studies with 50-74 being the most analysed range used in 11 studies. The most common FIT cut-off assessed was 20 µg Hb/g which was analysed in 12 studies. In 6 studies that analysed more than one cut-off, greater effectiveness was observed with lower FIT cut-off threshold.

CONCLUSIONS: The existing CEA evidence indicates that the widespread adoption of biennial stool-based testing in Europe might be sub-optimal, as the available evidence indicates annual screening is more effective and cost-effective. It is likely that many more lives could be saved throughout Europe if programmes move to more intensive annual screening. However, this has implications for expanding colonoscopy capacity in Europe. Our analysis highlights the needs for CEAs to consider a broad array of strategies in order to identify optimal policies.