Short-term vs. Long-term costs of stool-based testing compared to colonoscopies
The cost of screening per person in one year and in years 2-10 depends on the number of routine stool-based tests, subsequent diagnostic colonoscopies for positive stool tests, and routine colonoscopies. Programs emphasizing stool-based screening see more stool tests completed, lowering the cost per person in one year.[[174, 286, 399]] However, positive stool tests requiring diagnostic colonoscopies slightly increase costs.
In contrast, programs focusing on colonoscopies have more patients completing routine colonoscopies, increasing the cost per person in one year.[[174, 286, 399]] For years 2-10, costs differ due to screening intervals. Stool-test patients need annual tests to stay up to date,[[162, 287, 379, 399]] which requires investment and raises per-person costs.[[398, 434]] Conversely, patients with normal colonoscopy results only need screening every 10 years,[[162, 399]] reducing the cost per person for years 2-10 as more routine colonoscopies are completed.
Cited references for this diagram
The largest time cost was related to bowel preparation and undergoing the colonoscopy procedure; therefore, potentially, noninvasive fecal-based tests could result in lower burden in terms of time lost. Fecal tests, though, require much more frequent screening than colonoscopy and, therefore, may not effectively save much money over the long term.
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
Although the authors found that direct clinical costs were higher for colonoscopy-only screening programs than for FOBT/FIT-only programs, nonclinical costs did not vary by screening test type, suggesting that these programs have substantial fixed costs.
Joseph DA, DeGroff A. The CDC Colorectal Cancer Control Program, 2009-2015. Prev Chronic Dis. 2019 Dec 5;16:E159. doi: 10.5888/pcd16.190336. PMID: 31808418; PMCID: PMC6896829.
Based on a single screening cycle for FOBT, screening with FOBT, including colonoscopy follow-up, was less costly than colonoscopy, both per person and per program.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Data from the CRCSDP did not allow us to compare costs of an FOBT program with a colonoscopy program over multiple years, during which annually repeated FOBTs and diagnostic colonoscopies would accrue.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Additionally, the clinical cost of colonoscopy is almost four times the cost of FOBT/FIT per person when screening and diagnostic follow up tests are taken into account. Therefore, programs that use colonoscopy will only be able to screen about one-fourth the number of individuals during the early years of the program. As the colonoscopy screening interval is every 10 years compared to every year for FOBT/FIT, the numbers screened will converge over time but the initial screen will be delayed in the colonoscopy versus FOBT/FIT programs.
Subramanian S, Tangka FKL, Hoover S, Royalty J, DeGroff A, Joseph D. Costs of colorectal cancer screening provision in CDC's Colorectal Cancer Control Program: Comparisons of colonoscopy and FOBT/FIT based screening. Eval Program Plann. 2017 Jun;62:73-80. doi: 10.1016/j.evalprogplan.2017.02.007. Epub 2017 Feb 7. PMID: 28190597; PMCID: PMC5863533.
FOBT/FIT tests were the preferred approach when the primary goal was to offer first-time screening to a large cohort over a short period; we did not study FOBT/FIT with repeated testing. Future studies could assess additional program costs that may be incurred, to ensure adherence with colorectal cancer screening recommendations over the long term.
Subramanian S, Tangka FKL, Hoover S, Cole-Beebe M, Joseph D, DeGroff A. Comparison of Program Resources Required for Colonoscopy and Fecal Screening: Findings From 5 Years of the Colorectal Cancer Control Program. Prev Chronic Dis. 2019 Apr 25;16:E50. doi: 10.5888/pcd16.180338. PMID: 31022371; PMCID: PMC6513474.
The clinical cost of colonoscopy was almost 5 times the cost of FOBT/FIT per person when screening and diagnostic follow-up tests were included. Therefore, programs that use colonoscopy will only be able to screen about one-fifth the number of people that FOBT/FIT programs can for the same level of funding in the initial years of the program. This cost would only affect the number of people screened in the short term because colonoscopy is recommended every 10 years for those at average risk and with normal results, whereas FOBT/FIT is recommended to be performed annually. The clinical costs over a 10-year period for colonoscopy and FOBT/FIT may not be substantially different.
Subramanian S, Tangka FKL, Hoover S, Cole-Beebe M, Joseph D, DeGroff A. Comparison of Program Resources Required for Colonoscopy and Fecal Screening: Findings From 5 Years of the Colorectal Cancer Control Program. Prev Chronic Dis. 2019 Apr 25;16:E50. doi: 10.5888/pcd16.180338. PMID: 31022371; PMCID: PMC6513474.
Grantees in areas with a screening prevalence of 69.6% or higher allocated the smallest proportion of their screening promotion funds to outreach and education compared with grantees in areas with a screening prevalence of 69.5% or lower. The priority for grantees in areas with higher screening prevalence is navigating the patients along the screening continuum to ensure adherence with recommended screening, diagnostic follow-up, and referral for treatment recommendations; thus, these grantees spent more resources on patient navigation.
Tangka FKL, Subramanian S, Hoover S, Cole-Beebe M, DeGroff A, Joseph D, Chattopadhyay S. Expenditures on Screening Promotion Activities in CDC's Colorectal Cancer Control Program, 2009-2014. Prev Chronic Dis. 2019 Jun 6;16:E72. doi: 10.5888/pcd16.180337. PMID: 31172915; PMCID: PMC6583814.
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