Colorectal cancer screening program: cost effectiveness of systematic recall letters

The French colorectal cancer screening program has planned a stepwise strategy for delivery of a fecal occult blood test kit (Hemocult II) with an initial medical phase followed by systematic mailing of the test. Our aim was to ascertain the cost effectiveness of another recall method.

In the Bouches-du-Rhône administrative area, we conducted a cost effectiveness study comparing two second line delivery methods: mailing the test kit systematically to all non-responders to the initial medical phase (conventional strategy) and mailing the test kit to non-responders to the initial medical phase who requested a kit after receiving a recall letter (experimental strategy). After randomization, two groups were constituted among a sample of 10 930 persons.

The participation rate was significantly higher in the conventional strategy group than with the experimental strategy group (14.7% vs 8.3%; P<10(-5)). The mean cost of the conventional strategy test was 33.59 euros compared to only 18.50 euros with the experimental strategy (kit mailed only to persons who requested it).

These findings suggest that mailing a recall letter with a test order coupon can lead to substantial economy with a lost of participation of 6.4% at the test mailing phase. Better allocation of the spared cost (communication, information) might lead to increased participation, a hypothesis which should be tested further.