Cost-Effectiveness of Colonoscopy for Screening: What Matters Most?

Colorectal cancer (CRC) is a leading cause of cancer-related deaths worldwide. Worldwide, population-based systematic screening programs for the disease, which is essential to address this burden, rely primarily on fecal immunochemical testing (FIT). However, this test has multiple limitations, including an inability to detect right-sided CRCs and low individual adherence to follow-up colonoscopy among those with positive FIT results. Thus, primary colonoscopy screening is currently being explored as a more reliable strategy. Although randomized controlled trials published to date have not conclusively demonstrated beneficial effects of colonoscopy screening on mortality, limited evidence has suggested that improved participation rates in such programs may increase their effectiveness. That said, the evaluation of cost-effectiveness is another critical consideration when assessing these programs. To date, 11 simulation studies have compared the cost-effectiveness of colonoscopy-based screening with alternative strategies, of which six found that the colonoscopy-based screening strategy to be more cost-effective. Notably, among seven studies that assessed strategies based on repeat colonoscopies at regular intervals, five demonstrated favorable cost-effectiveness. However, among the 11 simulation studies, only five modeled the adenoma-carcinoma sequence, and only three accounted for interval cancers, limiting their clinical applicability. Moreover, repeated colonoscopy screening may increase the total number of procedures, potentially straining healthcare resources. Thus, in addition to evaluating mortality reduction, careful consideration of cost-effectiveness is essential in assessing the feasibility of implementing colonoscopy screening programs in public health practice.