Report in English with a Dutch summary (KCE reports 45A)

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124 Screening for Colorectal Cancer KCE reports vol.45 example at age 55 rather than the commonly mentioned 50 years, would be more cost effective. In the presence of scarce resources, a sensible decision-making process taking into account economic considerations is necessary. The combination of a widening of the target population and increasing the periodicity of screening can have a large impact on budgets and necessary capacity in a country. A trade-off between health gains and costs, both considering acceptability and affordability, is therefore necessary. To be able to provide the best available trade-off, investigation of age, periodicity and the other influential factors in a pilot program is recommended before implementing a full national program. Key messages gFOBT All available economic evaluations show that annual or biennial gFOBT followed by colonoscopy for screen positive participants is a cost effective intervention. However, estimates for the Incremental Cost Effectiveness Ratio (ICER) range from approximately 2000 per Life Year Gained to 30.000 per Disability Adjusted Life Year in a young target population. ICERs for gFOBT are mainly sensitive for the frequency of screening (biennial testing has better ICERs than annual screening), sensitivity and specificity of the test (the less sensitive but more specific nonrehydrated test had better ICERs than the more sensitive rehydrated test), and for the cost of testing. Choosing the right target population for gFOBT mass screening has an important influence on the ICERs: best ICERs are obtained at ages between 55 and 74. Below and above these ages ICERs are less favourable. The ICERs are very dependent on participation and compliance if program costs are included in the economic evaluation. iFOBT There is no evidence for a better ICER from any of the studied iFOBT tests vs. gFOBT, when comparing screening strategies to no screening. Colonoscopy All economic evaluations of colonoscopy as a screening tool are based on overly optimistic and unrealistic assumptions (especially regarding compliance).
KCE reports vol.45 Screening for Colorectal Cancer 125 7 ORGANISATION OF COLORECTAL CANCER SCREENING IN VARIOUS COUNTRIES 7.1 INTRODUCTION In 2003 the European Commission recommended to use FOBT as a screening tool for colorectal cancer in men and women between 50 and 74 183. Following this recommendation different pilot programs were launched in several European member states in order to determine the best screening strategy and the feasibility of a national screening program. In some European countries, however, initiatives were already taken at the end of the nineties. Only a few countries have adopted colorectal cancer screening as a public health policy. In several countries such as Germany, the Czech Republic, France, and the UK, FOBT screening or screening by endoscopy as a population screening has been introduced on the regional level. Several countries have programs conform the EC recommendations; others have ignored these recommendations and offer colonoscopy or sigmoidoscopy as a screening tool. Also outside Europe, national colorectal cancer screening guidelines gave birth to several initiatives. In this chapter, an overview of screening programs, pilot studies or public health programs in and outside Europe will be given. Recommendations and guidelines with regard to surveillance programs for high risk groups have been described in a previous chapter. As far as particular organised surveillance programs for high risk groups exist, they will be highlighted in this chapter. Information was collected from national and/or local governmental websites, and from private agencies when relevant. In order to validate or add to this information, contact was made with one or more experts in the specific country. Table 28 summarizes the available screening programs and pilots in different countries.
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