Result card

  • ECO1: What types of resources are used when delivering FIT and its comparators gFOBT and no screening(resource use identification)?

What types of resources are used when delivering FIT and its comparators gFOBT and no screening(resource use identification)?

Authors: Principal Investigators: Anna-Theresa Renner, Ingrid Rosian-Schikuta, Investigators: Nika Berlic, Neill Booth, Valentina Prevolnik Rupel

Internal reviewers: Pseudo178 Pseudo178, Pseudo283 Pseudo283, Pseudo291 Pseudo291, Pseudo293 Pseudo293, Pseudo294 Pseudo294, Pseudo297 Pseudo297, Pseudo298 Pseudo298

Nine articles from the systematic review of the literature outlined in the domain methodology section were used to identify what types of resources are used when delivering FIT and its comparator gFOBT. The remaining seven included studies did not identify the exact types of resources needed for the two tests.

In general, articles and studies that mention the type of costs and resources, divide those into the screening costs (organization, invitation and procedure, including the material resources), diagnostic follow-up in case of positive results and costs of treatment and care (in case of detected disease). The results of each of the included studies are presented below:


Berchi et al. s’ (2010) {11} study of cost-effectiveness analysis of the optimal threshold of an automated immunochemical test for colorectal cancer screening (study looks at only 1 round of screening), conducted from June 2004 to December 2005 in Calvados (France), identified the following costs, related to cancer management: (a) the costs of organizing the campaign; (b) the costs of offering screening tests including the costs of purchasing, distributing, and interpreting the tests; (c) the costs of performing confirmatory colonoscopies; (d) the costs of treating screened tumors.


In an earlier study Berchi et al. (2004) {12} undertook a cost-effectiveness analysis of two strategies for the  screening of colorectal cancer in France (in a study taking a 20-yeartime-horizon) where resource use is presented from the perspective of the screening organizer, i.e., the Social Security Service. Therefore, the modeling of costs included all direct costs related to screening, diagnosis and management of cancer. This included the costs of organizing the screening campaign (public information, running costs), costs of purchasing, distributing and interpreting the tests, costs of explorations performed in individuals with a positive test, costs of diagnosing cancers in individuals with a negative test, the costs of treating cancers and the costs of follow-up.


A Canadian report from 2009 (Heitman et al., 2009) {14} tried to identify what was the cost-effectiveness of FIT in colorectal cancer screening of average risk individuals in comparison with FOBT and colonoscopy, and a strategy of no screening (report included a lifetime horizon). The investigators specified a cost-effectiveness study conducted from the perspective of the publicly funded health care system. The implementation of this perspective seems to be inconsistent, because relevant costs included were direct health care costs as well as patient time and transport costs according to recent guidelines (REF: Canadian Agency for Drugs and Technologies in Health (CADTH). Guidelines for the economic evaluation of health technologies: Canada). Societal costs (costs due to lost productivity) were excluded in the primary analysis. They assumed that gFOBT and FIT screening would be requested during a person’s annual visit to the general practitioner. As a result, they only considered the costs of the gFOBT and FIT kit and related laboratory and processing costs when estimating the direct cost of gFOBT and FIT. The total cost of gFOBT and FIT also included the relevant non-medical costs (patient, caregiver time and travel costs) according to CADTH guidelines. It is likely that higher costs would occur, particularly if a screening program is organized outside the regularly scheduled medical visits. They also mentioned the direct costs for colonoscopy, which includes: the non-physician costs (capital, nursing, drug, and cleaning costs) and the physician-related fees for the procedure.


In their study Heitman et al. (2010) {15} performed an incremental cost-utility analysis using a Markov model. Their study was based on an economic evaluation of CRC screening in average risk North American individuals, over a lifetime time-horizon. Heitman et al. included into an economic evaluation the non-physician costs (capital, nursing, drugs, and cleaning costs) and the physician fees for the procedure into the overall screening costs. Because they assumed that stool-based screening would be offered at a person’s annual visit to their general practitioner, they only considered the costs of the screening kit and related laboratory/processing costs. For all screening modalities, the authors included the relevant patient and caregiver time and travel costs (non-medical costs), on the basis of available surveys for flexible sigmoidoscopy, colonoscopy, both FOBTs, and computed tomographic colonography (CTC). The nonmedical costs of FIT and fecal DNA were assumed to be the same as gFOBT. In the base case, they did not consider the capital costs of initiating or administering a screening program and thus assumed that screening would be opportunistic in all strategies. They have also considered the costs of treatment.


Lejeune et al. (2010) {17} examined cost-effectiveness of screening for colorectal cancer in France (Burgundy) using gFOBT versus FIT (time-horizon: 20 years, or until age of 85, or until death) and divided the costs into:

  1. the costs of organizing the screening program, including labor and equipment (similar for gFOBT and FIT screening programs).
  2. the costs of informing and inviting the population (similar for gFOBT and FIT screening programs). This also includes the design and printing of the invitation letter and of the information leaflet sent at the beginning of each screening campaign, the manpower for preparing the mail and postage, the training cost of general practitioners (GPs), and the cost of informing the entire medical profession.
  3. the distribution costs, including the costs for screening conducted during a regular consultation with a GP (taking into account the purchase price of the test kit and a special fee paid to GPs according to the number of tests received at the central analysis center, therefore, depending on participation in the screening program), the cost of the test sent by mail if the screening test was not performed during the medical phase (test kit, letter, envelope, instruction for use, stamp), and the cost of a reminder letter.
  4. the cost of test revelation in a centralized analysis center included overhead costs, capital expenditure, running costs, and labor. The process cost also included the cost of sending test results to the participants and to their GPs.
  5. the costs of a colonoscopy performed after a positive test.
  6. the costs of the follow-up after large adenoma resection.
  7. the costs of the follow-up of treated CRCs.
  8. the average costs of treatment of CRC by stage.


Parekh et al. (2008) {18} in their study, which was modelled on a US population, examined in detail the potential impact of imperfect adherence on the effectiveness and cost-effectiveness of screening strategies (time horizon: until age 100 or death). They included the costs of screening, diagnostic testing, treatment of possible complications (e.g. ruptures from colonoscopies) and CRC care. If F-DNA, gFOBT or FIT test were positive, colonoscopy followed with polypectomy and biopsy as necessary. If colonoscopy was normal after a positive non-invasive test, the non-invasive test was assumed to be false positive and screening resumed in 10 years with the primary screening strategy.


A Dutch study that took a 10-years time-horizon and referred to a cost-effectiveness analysis and Colorectal cancer screening comparing no screening, immunochemical and guaiac fecal occult blood tests, carried out by van Rossum et al. (2011) {19} also considered only direct healthcare costs. The costs of the two FOBTs consisted of costs that were independent and dependent on the type of test. Ignoring the differences in participation between the FIT and gFOBT, costs independent of the type of test were costs related to the invitation for screening (e.g. letters and information brochures), basic administration of the tests, feedback of test results to the patient and postal charges. The costs which are directly dependent on the type of test were costs of the test itself and costs for laboratory analyses. To represent the costs of the actual test kits they used retail prices. The costs of the laboratory analysis of the FOBTs were based on costs for administration, laboratory work and correspondence of test results for returned tests only. Consequently, participation rates influenced the total costs of each screening strategy. A complete test kit of Hemoccult-II (gFOBT) includes a number of tests and the test developer solution. OC-Sensor testing materials (FIT) are made available separately and were, therefore, calculated for returned tests only. The costs of the automated analyzer OC-micro, used for the analysis of the OC-Sensor, were also included into the costs of a returned FIT given the assumption of 100,000 tests per year and depreciated over 3 years. All other clinical costs for the follow-up of positive FOBT results (e.g., CRC surgery) were given as charges and directly derived from the Dutch Health Care Authority database (NZA). The NZA is the supervisory body for all the healthcare markets in the Netherlands and supervises both healthcare providers and insurers in the curative markets and in the long-term care markets.


Sharp et al.’s (2012) {20} study is based on cost-effectiveness of population-based screening for colorectal cancer: a comparison gFOBT, FIT and flexible sigmoidoscopy (time-horizon: cohort entered simulation at age 30 until age 100 or death) and evaluated in Ireland. The study included direct costs, valued in 2008 Euros, associated with screening and cancer management. Costs of gFOBT and FIT kits and associated processing were estimated following discussion with the National Cancer Screening Service, test suppliers, and laboratory staff, and using Department of Health and Children salary scales. They do not specify the types of resources included in their study, only stating at the end that their model did not incorporate the costs of establishing the infrastructure to implement population-based screening for colorectal cancer. The model was developed from a third-party payer perspective, in this case a provincial organization that decides on funding for a provincial screening program for colorectal cancer. Therefore, lost productivity costs, which would be necessary to give a wider societal perspective, were not incorporated.


Wilschut et al. (2011) {24} undertook a cost-effectiveness analysis, comparing Fecal Occult Blood Testing (gFOBT and FIT) when colonoscopy capacity is limited, and depicted the different cost components in more detail. Their study is based on 30 years time-horizon. In their analysis they included (a) the screening costs for FOBT screening such as organizational costs, costs of test kits, costs of analysis of the tests (that includes material and personnel needed during the process of registration, analysis, and authorization of returned tests) and (b) the costs of CRC treatment divided into three clinically relevant phases of care: initial treatment, continuous care, and terminal care.


Zauber et al. (2010) {5} undertook research on the cost-effectiveness of colonoscopy and included several types of resources within their cost-effectiveness analysis: costs that occur during procedures, costs of tests associated with CRC screening, costs of complications of screening, and treatment costs. These costs included the facility charges (as applicable) and physician services charges. Thus beneficiaries’ copayments are not reflected in the analysis. They also conducted an analysis from a modified societal perspective, by including direct costs borne by beneficiaries as well as estimated patient time costs, but excluding costs caused by lost productivity caused by early death or disability.


From this literature it could be concluded that organized screening contains:

  • the costs of screening (organization of screening, screening procedure etc.). However, some studies {11, 12, 14, 15} only considered the costs of FIT/gFOBT kits and related laboratory and processing costs, because they have assumed that gFOBT and FIT screening would be requested during a person’s annual visit to the general practitioner.
  • the costs of diagnostic follow-up in case of positive results
  • the costs of treatment in case of detected disease (the costs of all 4 stages: stage I, stage II, stage III and stage IV) (the treatment costs of possible complications (e.g. ruptures from colonoscopy) were also included)
  • non-medical costs (patient/ caregiver time and travel costs)


In general, the types of resources used when undertaking FIT and gFOBT screening will be similar, due to the similarity of the alternative screening procedures. The resources used for screening include those necessary for the organization of screening (e.g., sending invitation, distributing the kits, sending re-invitation, and possibly collecting the samples), those for the screening procedure (e.g., laboratory analysis, sending information concerning results, and diagnostic follow-up in case of positive results), and those for treatment in case of detected disease. This results card (ECO 1) summarises the types of costs included in the literature. Attention should be drawn to fact that the majority of studies failed to mention costs associated with lost or re-gained productivity. Only six studies mentioned costs associated with lost productivity, but none of these included such costs into the analysis. The exclusion of productivity-related costs has both economic and ethical dimensions, and is a matter which is subject to much methodological debate. 

Renner P et al. Result Card ECO1 In: Renner P et al. Costs and economic evaluation In: Jefferson T, Cerbo M, Vicari N [eds.]. Fecal Immunochemical Test (FIT ) versus guaiac-based fecal occult blood test (FOBT) for colorectal cancer screening [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali; 2014. [cited 16 June 2021]. Available from: