Cost-effectiveness and budget impact analysis of a population-based screening program for colorectal cancer


      • Colorectal cancer (CRC) is the third most common cancer in Belgium.
      • A CRC screening program has been introduced in Flanders (Belgium) since 2013.
      • CRC screening is predicted to decrease CRC incidence and mortality on the long term.
      • CRC screening is predicted to increase quality of life, but against an extra cost.
      • The Flemish program is estimated to be very cost-effective and should be continued.



      Colorectal cancer (CRC) is one of the leading causes of cancer mortality in Belgium. In Flanders (Belgium), a population-based screening program with a biennial immunochemical faecal occult blood test (iFOBT) in women and men aged 56–74 has been organised since 2013. This study assessed the cost-effectiveness and budget impact of the colorectal population-based screening program in Flanders (Belgium).


      A health economic model was conducted, consisting of a decision tree simulating the screening process and a Markov model, with a time horizon of 20 years, simulating natural progression. Predicted mortality and incidence, total costs, and quality-adjusted life-years (QALYs) with and without the screening program were calculated in order to determine the incremental cost-effectiveness ratio of CRC screening. Deterministic and probabilistic sensitivity analyses were conducted, taking into account uncertainty of the model parameters.


      Mortality and incidence were predicted to decrease over 20 years. The colorectal screening program in Flanders is found to be cost-effective with an ICER of 1681/QALY (95% CI −1317 to 6601) in males and €4,484/QALY (95% CI −3254 to 18,163). The probability of being cost-effective given a threshold of €35,000/QALY was 100% and 97.3%, respectively. The budget impact analysis showed the extra cost for the health care payer to be limited.


      This health economic analysis has shown that despite the possible adverse effects of screening and the extra costs for the health care payer and the patient, the population-based screening program for CRC in Flanders is cost-effective and should therefore be maintained.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Stichting Tegen Kanker
        Distribution of Cancer in Males and Females, Belgium.
        • Stichting Tegen Kanker
        Colorectal Cancer - General Data.
        • European commission
        European Guidelines for Quality Assurance in Colorectal Cancer Screening and Diagnosis.
        • Council of the European Union
        Cancer screening in the European Union.
        in: Report on the Implementation of the Council Recommendation on Cancer Screening. 2003
        • U.S.Preventive Services Task Force
        Screening for Colorectal Cancer.
        • Faivre J.
        • Dancourt V.
        • Lejeune C.
        • Tazi M.A.
        • Lamour J.
        • Gerard D.
        • et al.
        Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study.
        Gastroenterology. 2004; 126: 1674-1680
        • Hardcastle J.D.
        • Chamberlain J.O.
        • Robinson M.H.
        • Moss S.M.
        • Amar S.S.
        • Balfour T.W.
        • et al.
        Randomised controlled trial of faecal-occult-blood screening for colorectal cancer.
        Lancet. 1996; 348: 1472-1477
        • Kronborg O.
        • Fenger C.
        • Olsen J.
        • Jorgensen O.D.
        • Sondergaard O.
        Randomised study of screening for colorectal cancer with faecal-occult-blood test.
        Lancet. 1996; 348: 1467-1471
        • Zorzi M.
        • Fedeli U.
        • Schievano E.
        • Bovo E.
        • Guzzinati S.
        • Baracco S.
        • et al.
        Impact on colorectal cancer mortality of screening programmes based on the faecal immunochemical test.
        Gut. 2015; 64: 784-790
        • Ventura L.
        • Mantellini P.
        • Grazzini G.
        • Castiglione G.
        • Buzzoni C.
        • Rubeca T.
        • et al.
        The impact of immunochemical faecal occult blood testing on colorectal cancer incidence.
        Dig Liver Dis. 2014; 46: 82-86
        • Sharp L.
        • Tilson L.
        • Whyte S.
        • O'Ceilleachair A.
        • Walsh C.
        • Usher C.
        • et al.
        Cost-effectiveness of population-based screening for colorectal cancer: a comparison of guaiac-based faecal occult blood testing, faecal immunochemical testing and flexible sigmoidoscopy.
        Br J Cancer. 2012; 106: 805-816
        • Telford J.J.
        • Levy A.R.
        • Sambrook J.C.
        • Zou D.
        • Enns R.A.
        The cost-effectiveness of screening for colorectal cancer.
        CMAJ. 2010; 182: 1307-1313
        • Sobin L.H.
        • Gospodarowicz M.K.
        • Wittekind C.
        TNM Classification of Malignant Tumours.
        7th ed. 2009
        • Stichting kankerregister
        Prevalence of Colorectal Cancer.
        2010: 2013
        • Brenner H.
        • Altenhofen L.
        • Stock C.
        • Hoffmeister M.
        Incidence of colorectal adenomas: birth cohort analysis among 4.3 million participants of screening colonoscopy.
        Cancer Epidemiol Biomarkers Prev. 2014; 23: 1920-1927
        • GLOBOCAN
        Incidence/Mortality Rates: Cancers by Population.
        • Centrum voor Kankeropsporing
        Annual report screening program 2013.
        • Goede S.L.
        • van Roon A.H.
        • Reijerink J.C.
        • van Vuuren A.J.
        • Lansdorp-Vogelaar I.
        • Habbema J.D.
        • et al.
        Cost-effectiveness of one versus two sample faecal immunochemical testing for colorectal cancer screening.
        Gut. 2013; 62: 727-734
        • Wilschut J.A.
        • Hol L.
        • Dekker E.
        • Jansen J.B.
        • van Leerdam M.E.
        • Lansdorp-Vogelaar I.
        • et al.
        Cost-effectiveness analysis of a quantitative immunochemical test for colorectal cancer screening.
        Gastroenterology. 2011; 141: 1648-1655
        • Kovarova J.T.
        • Zavoral M.
        • Zima T.
        • Zak A.
        • Kocna P.
        • Kohout P.
        • et al.
        Improvements in colorectal cancer screening programmes – quantitative immunochemical faecal occult blood testing – how to set the cut-off for a particular population.
        Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2012; 156: 143-150
        • Cullen J.
        • Schwartz M.D.
        • Lawrence W.F.
        • Selby J.V.
        • Mandelblatt J.S.
        Short-term impact of cancer prevention and screening activities on quality of life.
        J Clin Oncol. 2004; 22: 943-952
        • Pacolet J.
        • De Coninck A.
        • Hedebouw G.
        • Cabus S.
        • Spruytte N.
        De medische en niet-medische kosten van kankerpatiënten.
        HIVA-K.U, Leuven2011
        • Tilson L.
        • Sharp L.
        • Usher C.
        • Walsh C. S. W.
        • O’Ceilleachair A.
        • Stuart C.
        • et al.
        Cost of care for colorectal cancer in Ireland: a health care payer perspective.
        Eur J Health Econ. 2012; 13: 511-524
        • Hakkaart-van Roijen L.
        • Tan S.
        • Bouwmans C.A.M.
        Handleiding voor kostenonderzoek: Methoden en standaard kostprijzen voor economische evaluaties in de gezondheidszorg.
        College voor Zorgverzekeringen, 2010
        • Federaal Kenniscentrum voor de gezondheidszorg
        Belgian Guidelines for Economic Evaluations and Budget Impact Analyses.
        2nd ed. 2012
        • Hol L.
        • Wilschut J.A.
        • Van B.M.
        • van Vuuren A.J.
        • van d V.
        • Reijerink J.C.
        • et al.
        Screening for colorectal cancer: random comparison of guaiac and immunochemical faecal occult blood testing at different cut-off levels.
        Br J Cancer. 2009; 100: 1103-1110
        • Hassan C.
        • Benamouzig R.
        • Spada C.
        • Ponchon T.
        • Zullo A.
        • Saurin J.C.
        • et al.
        Cost effectiveness and projected national impact of colorectal cancer screening in France.
        Endoscopy. 2011; 43: 780-793
        • Lejeune C.
        • Dancourt V.
        • Arveux P.
        • Bonithon-Kopp C.
        • Faivre J.
        Cost-effectiveness of screening for colorectal cancer in France using a guaiac test versus an immunochemical test.
        Int J Technol Assess Health Care. 2010; 26: 40-47
        • Heresbach D.
        • Chauvin P.
        • Grolier J.
        • Josselin J.M.
        Cost-effectiveness of colorectal cancer screening with computed tomography colonography or fecal blood tests.
        Eur J Gastroenterol Hepatol. 2010; 22: 1372-1379
        • Fobelets M.
        • Pil L.
        • Putman K.
        • Annemans L.
        Cost-Effectiveness and Budget Impact Analysis of a Population-Based Screening Program for Breast Cancer.
        2016 ([in submission])
        • Hewitson P.
        • Glasziou P.
        • Irwig L.
        • Towler B.
        • Watson E.
        Screening for colorectal cancer using the faecal occult blood test, Hemoccult.
        Cochrane Database Syst Rev. 2007; CD001216
        • Brenner H.
        • Tao S.
        Superior diagnostic performance of faecal immunochemical tests for haemoglobin in a head-to-head comparison with guaiac based faecal occult blood test among 2235 participants of screening colonoscopy.
        Eur J Cancer. 2013; 49: 3049-3054
        • Guittet L.
        • Bouvier V.
        • Mariotte N.
        • Vallee J.P.
        • Arsene D.
        • Boutreux S.
        • et al.
        Comparison of a guaiac based and an immunochemical faecal occult blood test in screening for colorectal cancer in a general average risk population.
        Gut. 2007; 56: 210-214
        • Pickhardt P.
        • Hassan C.
        • Laghi A.
        • Zullo A.
        • Kim D.H.
        • Morini S.
        Cost-effectiveness of colorectal cancer screening with computed tomography colonography: the impact of not reporting diminutive lesions.
        Cancer. 2007 Jun 1; 109: 2213-2221
        • Hur C.
        • Chung D.C.
        • Schoen R.E.
        • Gazelle G.S.
        The management of small polyps found by virtual colonoscopy: results of a decision analysis.
        Clin Gastroenterol Hepatol. 2007 Feb; 5: 237-244
        • Manser C.N.
        • Bauerfeind P.
        Impact of socioeconomic status on incidence, mortality, and survival of colorectal cancer patients: a systematic review.
        Gastrointest Endosc. 2014; 80: 42-60
        • Rabeneck L.
        • Lansdorp-Vogelaar I.
        Assessment of a cancer screening program.
        Best Pract Res Clin Gastroenterol. 2015; 29: 979-985