Economic Evaluation of CDC’s Colorectal Cancer Control Program
Among cancers that affect both men and women, colorectal cancer is the second leading cause of cancer deaths in the United States. Screening tests can find colorectal cancer early, when treatment works best. But many people have not been screened as recommended.
From 2009 to 2015, CDC’s Colorectal Cancer Control Program (CRCCP) funded 25 states and 4 tribal organizations to increase colorectal cancer screening rates among men and women between 50 to 75 years of age. Grantees used their funds to promote screening and to provide screening services to low-income, uninsured people.
CDC researchers performed two studies that looked at how CRCCP grantees spent their funds to promote screening and to provide screening, and a third study that looked at patients’ and caregivers’ out-of-pocket costs. These studies can help guide future colorectal cancer screening programs.
Spending for Screening Promotion
The CRCCP encouraged grantees to promote increased use of colorectal cancer screening in ways recommended by the Guide to Community Preventive Services (Community Guide), called evidence-based interventions. This study looks at the screening promotion interventions that the grantees used for the first three years of the CRCCP (July 2009 to June 2011), and the proportion of funds they spent on each type of intervention.
All grantees used small media activities, and more than 90% used other Community Guide-recommended interventions such as patient reminders, provider assessment, or patient navigation. The majority of funds were spent on evidence-based interventions. But about one-third of funds were spent on mass media, which is not recommended due to a lack of evidence that it increases colorectal cancer screening rates.
This study did not directly assess increases in population screening use, but suggested that a 5% increase in colorectal cancer screening could have been achieved for less than $35 per person. Based on all expenditures, the projected cost per person screened for a 1%, 5%, and 10% increase in state-level screening proportions are $172, $34, and $17, respectively.
Spending for Screening Provision
This study looked at the costs of providing screening tests to uninsured people for 23 CRCCP grantees during the first three years of the program. It compared the clinical and non-clinical costs of 14 programs that screened for colorectal cancer using colonoscopy to those of nine programs that used fecal occult blood tests (FOBT) or fecal immunochemical tests (FIT).
Programs that used colonoscopy had higher clinical costs per person screened than programs that used FOBT or FIT. The average annual clinical cost for screening and diagnostic services per person served was $1,150 for colonoscopy-based programs, compared to $304 for FIT/FOBT-based programs.
Non-clinical costs include all costs not directly related to providing screening tests, such as the costs for patient navigation, program management, quality assurance, professional development, and program evaluation. Overall, both kinds of programs had similar non-clinical costs per person served of about $1,000.
Costs to Patients and Caregivers
Although the colonoscopies were free, the patients had significant costs due to lost productivity and travel. Patients spent an average of about 24 hours preparing for, traveling to and from, and getting a colonoscopy, plus about five hours recovering from the colonoscopy. At an average hourly wage of $11.68, the total cost in lost time is about $336 for the patient and $79 for the caregiver. In addition, about $17 was spent for transportation and other costs.
The cost of getting a “free” colonoscopy is substantial for a low-income patient. Also, many low-income patients may not have paid sick leave. This could help explain why many people with low education and low socioeconomic status are not screened as recommended. More research is needed to learn how much these costs prevent people with a low income and no health insurance from getting free colorectal cancer screening tests.
Tangka FKL, Subramanian S. Importance of implementation economics for program planning—evaluation of CDC’s Colorectal Cancer Control Program. Evaluation and Program Planning 2016.
Tangka FKL, Subramanian S, Hoover S, Royalty J, Joseph K, DeGroff A, Joseph D, Chattopadhyay S. Costs of promoting cancer screening: evidence from CDC’s Colorectal Cancer Control Program (CRCCP). Evaluation and Program Planning 2016.
Subramanian S, Tangka FKL, Hoover S, Royalty J, DeGroff A, Joseph D. Costs of colorectal cancer screening provision in CDC’s Colorectal Cancer Control Program: comparisons of colonoscopy and FOBT/FIT based screening. Evaluation and Program Planning 2016.
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients’ and caregivers’ costs for colonoscopy-based colorectal cancer screening: experience of low-income individuals undergoing free colonoscopies. Evaluation and Program Planning 2016.