Results and cost of a population-based biennial faecal occult blood colorectal cancer screening program.



B. Denis
, P. Perrin, J.F. Vies, J.P. Milleliri, F. Vagne, G. Ventre, J.M. Boyaval, F. Planchon.

ADECA 68, Hopital Pasteur, Colmar, France


Introduction        

Despite strong evidence that screening reduces both colorectal cancer (CRC) mortality and incidence, CRC screening tests remain underutilized.

Aim        

To report the results and cost of a population-based biennial faecal occult blood (FOBT) CRC screening program in the French area of Haut-Rhin (710 000 inhabitants), an area with one of the highest CRC incidence in Europe.

Methods        

All 188,438 residents aged 50-74 years were invited by mail for a CRC screening using a non rehydrated FOBT (Hemoccult II). FOBTs were first provided by the GPs and then directly mailed to persons who didn?t comply after 2 invitations. The processing of FOBTs was centralized.

Results        

87,790 people (46.6%) completed a FOBT and 18,995 (10.1%) were excluded for recent CRC screening, high risk of CRC or concurrent severe disease, so that adjusted participation rate was 51.8%. Participation was higher in women (54.2%) than in men (49.4%)(p<0.001) and ranged from 45.4% to 59.8% according to districts. Participation was lower below 60 years (47.5%) than after (56.6%). FOBT positivity rate was 3.3%, higher in men (3.9%) than in women (2.8%)(p<0.001). To date 2,408 colonoscopies were performed. The positive predictive value was 10% for CRC (women 7.2%, men 12.5%), 20.8% for advanced adenomas (women 13.4%, men 26.9%) and 42.2% for neoplasia (women 30.6%, men 51.8%). Detection rates for neoplasia and CRC were 11.6 and 2.8 per 1,000 people screened. 27.2% of CRC were in situ, 50% of invasive CRC were stage I and 23.4% stage II. The rate of proximal advanced neoplasia increased with age (16.5% below 65 years, 25.4% after) but didn?t differ with gender. Flexible sigmoidoscopy alone would have missed 21.4% of people with advanced neoplasia, without significant difference according to age and gender. The overall cost of this biennial screening program (without the fees related to colonoscopies) was $2.7 million: fixed cost was $1.88 million ($5 per year per eligible person) and variable cost $0.82 million ($4 per screened person). The cost per screened person was $30 and the cost to find an early-stage neoplasia (advanced adenoma or in situ CRC or stage I CRC) was $4,300.

Conclusion        

Participation and diagnostic yield of randomised controlled trials of FOBT screening are reproducible at a reasonable cost in the real world through an organized population-based program involving GPs. Efforts should be made to enhance the participation of men and people below 60 years.



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