Modeling tradeoffs between FIT and colonoscopy-based approaches

The CDC’s Colorectal Cancer Control Program (CRCCP) funds grantees, including states, universities, and tribal organizations, to partner with clinics in order to improve colorectal cancer (CRC) screening among individuals ages 45-75. The program has both provided CRC screenings (e.g., FITs, colonoscopies) directly to low-income, medically underserved individuals and promoted CRC screening by providing training and technical assistance to support the implementation of evidence-based interventions (EBIs).

While we developed the tools below to inform decision-making among CRCCP program leadership and individual grantees and their partner clinics, we believe they will be useful for any public health professionals or practitioners working to improve CRC screening and outcomes in low-income, medically underserved populations.

Cost calculator and comparison of FIT and colonoscopy-based approaches

We considered the scenario in which clinics or other public health initiatives are deciding whether to invest in FIT-based or screening colonoscopy-based programs to improve screening. To explore this, we wanted to understand the impact on health outcomes and costs of both FIT-based programs and colonoscopy-based programs. With FIT-based programs, we considered the impact of variation in year-to-year FIT adherence and/or diagnostic colonoscopy adherence after a positive FIT. To illustrate, we simulated CRC outcomes (CRC cases, CRC deaths, life-years gained) for the cohort of approximately 78,000 individuals who completed at least one CRC screening through the CRCCP between 2009-2020. Recognizing that costs to obtain different levels of screening completion are uncertain, we created a cost calculator that allows users to modify our assumptions about both clinical costs and the cost of outreach to improve adherence levels.

Exploring tradeoffs in different approaches to providing and promoting CRC screening

We developed causal loop diagrams to document and synthesize the tradeoffs when considering different approaches to improving CRC screening in low-income, medically underserved populations. The causal relationships documented were identified through a literature review of 38 prior publications evaluating and learning from CRCCP initiatives and supplemented, where needed, with additional evidence about CRC screening.

Five important themes emerged from this analysis:

• How to select and implement evidence-based interventions
• How to improve sustainability of evidence-based interventions
• Recommendations for improved CRC screening and testing across modalities
• Understanding cost tradeoffs across screening modalities over time
• Factors affecting cost-effectiveness and efficiency of evidence-based interventions