Efficacy and cost-effectiveness of extending risk-stratified colorectal cancer screening: evidence from China’s first province-wide program

BACKGROUND: China accounts for nearly 30% of global colorectal cancer (CRC) cases but has only 3% screening coverage, underscoring the urgent need to expand coverage. We evaluated the efficacy and cost-effectiveness of extending risk-stratified CRC screening based on the first province-wide, full-coverage initiative in China (2020-2024). METHODS: This population-based study covered 17 780 462 average-risk residents aged 50-74. Those participants were stratified using the Revised Asia-Pacific Colorectal Screening Score (APCS) and fecal immunochemical testing (FIT). High-risk participants (APCS ≥5 or FIT-positive) were referred for colonoscopy. A health care system perspective Markov model simulated a cohort of 100 000 individuals to compare screening strategies by initiation age and frequency. Outcomes included screening yield (participation, detection, and death averted), resource utilization (colonoscopies, costs per lesion detected, and number needed to screen), and cost-effectiveness. Incremental cost-effectiveness ratios (ICERs), benchmarked against three times per capita GDP (USD $ 53 235 in 2023) per quality-adjusted life-year (QALY) gained. Sensitivity analyses were performed. RESULTS: Among 10 364 955 eligible participants, 1 582 606 (15.27%) were high-risk, with 38.92% colonoscopy compliance. Screening detected 59 954 advanced adenomas (AAs) and 5708 CRCs, with 11 and 108 colonoscopies needed per lesion, respectively. The cost per AA and CRC detected was $ 1588 and $ 16 684. All screening strategies were cost-effective regardless of the starting age or frequency, yielding ICERs of $ 6718- $ 21 177 per QALY. Annual screening starting at 40-44 years achieved optimal effectiveness (19 955 QALYs gained, 1126 CRC deaths averted per 100 000). CONCLUSION: This first province-wide, full-coverage screening initiative demonstrates the effectiveness and cost-effectiveness of extending risk-based CRC screening in resource-rich regions of China, supporting expanded coverage and informing policy decisions for CRC prevention in similar settings.