Effectiveness and cost-effectiveness of risk-adapted colorectal cancer screening: a randomized controlled trial and modeling analysis

Hong-Da Chen; Bin Lu; Ju-Fang Shi; Yue-Yang Zhou; Ling-Bin Du; Xian-Zhen Liao; Dong-Hua Wei; Dong Dong; Yi Gao; Chen Zhu; Rong-Biao Ying; Wei-Fang Zheng; Shi-Peng Yan; Hai-Fan Xiao; Juan Zhang; Yun-Xin Kong; Fu-Rong Li; Na Li; Jia-Hui Luo; Chen-Yu Luo; Hermann Brenner; Min Dai

doi:10.1186/s40779-025-00671-7

Your Location：

Home >

Browse articles >

Effectiveness and cost-effectiveness of risk-adapted colorectal cancer screening: a randomized controlled trial and modeling analysis

RESEARCH | Updated：2026-08-20

- Effectiveness and cost-effectiveness of risk-adapted colorectal cancer screening: a randomized controlled trial and modeling analysis
- Effectiveness and cost-effectiveness of risk-adapted colorectal cancer screening: a randomized controlled trial and modeling analysis
- Military Medical Research 2026年13卷第6期页码：881-893
- Affiliations：
  
  Center for Prevention and Early Intervention, National Infrastructures for Translational Medicine, Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
  Department of Cancer Epidemiol-ogy, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
  Office of Cancer Screening, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
  Department of Cancer Prevention, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Cancer Hospital of University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou 310022, China
  Department of Cancer Prevention, Hunan Cancer Hospital, Changsha 410013, China
  Department of Cancer Prevention, Anhui Provincial Cancer Hospital, Hefei 230031, China
  Office of Cancer Preven-tion and Treatment, Xuzhou Cancer Hospital, Xuzhou 221005, Jiangsu, China
  Department of Colorectum Surgery, Tumor Hospital of Yunnan Province, Third Affiliated Hospital of Kunming Medical University, Kunming 650118, China
  Department of Surgical Oncology, Taizhou Cancer Hospital, Taizhou 317502, Zhejiang, China
  Department of Anorectal Diseases, Lanxi Hospital of Tradi-tional Chinese Medicine, Jinhua 321100, Zhejiang, China
  Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Baden-Württemberg, Germany
  German Cancer Con-sortium (DKTK), German Cancer Research Center (DKFZ), 69120 Heidelberg, Baden-Württemberg, Germany
- Author bio：
  
  * Hong-Da Chen chenhongda@pumch.cn
  Min Dai daimin2002@hotmail.com
- Funds：
  
  the Chinese Academy of Medical Science Innova-tion Fund for Medical Science(2022-I2M-1-003);the National Natural Science Foundation of China(82173606;82273726);the Beijing Nova Program of Science and Technology(20230484397)
- DOI：10.1186/s40779-025-00671-7
  中图分类号：
- 收稿：2025-06-19，
  
  录用：2025-11-04，
  
  网络首发：2025-11-24，
  
  纸质出版：2026-06
- Accepted：
Scan QR Code
Hong-Da Chen, Bin Lu, Ju-Fang Shi, 等. Effectiveness and cost-effectiveness of risk-adapted colorectal cancer screening: a randomized controlled trial and modeling analysis[J]. Military Medical Research, 2026,13(6):881-893.

Hong-Da Chen, Bin Lu, Ju-Fang Shi, et al. Effectiveness and cost-effectiveness of risk-adapted colorectal cancer screening: a randomized controlled trial and modeling analysis[J]. Military Medical Research, 2026, 13(6): 881-893.
Hong-Da Chen, Bin Lu, Ju-Fang Shi, 等. Effectiveness and cost-effectiveness of risk-adapted colorectal cancer screening: a randomized controlled trial and modeling analysis[J]. Military Medical Research, 2026,13(6):881-893. DOI： 10.1186/s40779-025-00671-7.

Hong-Da Chen, Bin Lu, Ju-Fang Shi, et al. Effectiveness and cost-effectiveness of risk-adapted colorectal cancer screening: a randomized controlled trial and modeling analysis[J]. Military Medical Research, 2026, 13(6): 881-893. DOI： 10.1186/s40779-025-00671-7.

摘要

Abstract

Background

Risk-adapted colorectal cancer (CRC) screening has the potential to balance effectiveness with resource demands

yet evidence comparing it with established methods remains limited. This study aims to compare out-comes of risk-adapted CRC screening with colonoscopy and fecal immunochemical test (FIT) strategies.

Methods

We adopted a hybrid methodology combining real-world data from a population-based CRC screening randomized controlled trial (TARGET-C) with projections from a validated Markov-based microsimulation model (MIMIC-CRC). The TARGET-C trial enrolled 19

582 participants aged 50–74 years from 6 centers in China

randomized in a 1: 2: 2 ratio into 3 groups. After applying the exclusion criteria

the final analysis included 3883 participants in the one-time colonoscopy group

7793 in the annual FIT group

and 7697 in the risk-adapted screening group. In the latter group

screening allocation was determined by a composite risk score incorporating age

sex

family his-tory of CRC

smoking status

and body mass index

with high-risk participants referred for colonoscopy and low-risk participants for FIT. The primary outcome was detection rates of advanced neoplasm (CRC and advanced adenoma)over 4 rounds. Secondary outcomes included screening participation

colonoscopy demand

and costs from a societal perspective. Long-term effectiveness and cost-effectiveness were modeled over 15 years using MIMIC-CRC.

Results

Across 4 rounds

overall participation rates (attending at least one screening round) were 42.3% (colonos-copy)

99.8% (FIT)

and 92.5% (risk-adapted). Detection rates of advanced neoplasms were 2.8%

2.3%

and 2.6%

respectively

with no significant differences (

0.05). Colonoscopies needed to detect 1 advanced neoplasm were 15.4

7.9

and 9.3

respectively. From a societal perspective

the cost for detecting 1 advanced neoplasm was 15

341

754

and 24

300 Chinese Yuan

respectively. Over 15 years

risk-adapted screening reduced incidence by 16.7%and mortality by 21.5% compared with no screening

slightly less effective than colonoscopy (24.6% and 24.8%

respectively). Under observed real-world adherence

colonoscopy was the most cost-effective; under perfect full adherence

risk-adapted screening was the most cost-effective.

Conclusions

In this population-based CRC screening trial

risk-adapted screening

colonoscopy

and FIT demon-strated comparable effectiveness

but differed in participation rates

resource utilization

and cost-effectiveness. Risk-adapted screening could serve as a complementary approach to established strategies

particularly when health resources are limited.

Trial registration

Chinese Clinical Trial Registry (ChiCTR1800015506).

关键词

Keywords

references

Bray F , Laversanne M , Sung H , Ferlay J , Siegel RL , Soerjomataram I , et al . Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries . CA Cancer J Clin . 2024 ; 74 ( 3 ): 229 – 63 .

Cardoso R , Guo F , Heisser T , Hackl M , Ihle P , De Schutter H , et al . Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population‑based study . Lancet Oncol . 2021 ; 22 ( 7 ): 1002 – 13 .

Siegel RL , Wagle NS , Cercek A , Smith RA , Jemal A . Colorectal cancer statistics, 2023 . CA Cancer J Clin . 2023 ; 73 ( 3 ): 233 – 54 .

Brenner H , Heisser T , Cardoso R , Hoffmeister M . Reduction in colorectal cancer incidence by screening endoscopy . Nat Rev Gastroenterol Hepa‑tol . 2024 ; 21 ( 2 ): 125 – 33 .

Wang JC , Zhao L , Yu XY , Wu TP , Xia CF , Shi JF , et al . Diagnostic efficacy of fecal‑based miR‑92a for advanced colorectal neoplasia: a prospective multicenter screening trial . Mil Med Res . 2025 ; 12 ( 1 ): 30 .

US Preventive Services Task Force , Davidson KW , Barry MJ , Mangione CM , Cabana M , Caughey AB , et al . Screening for colorectal cancer: US preventive services task force recommendation statement . JAMA . 2021 ; 325 ( 19 ): 1965 – 77 .

Li J , Yao H , Lu Y , Zhang S , Zhang Z , Society of Digestive Endoscopy of the Chinese Medical Association . Chinese national clinical practice guidelines on prevention, diagnosis and treatment of early colorectal cancer . Chin Med J (Engl) . 2024 ; 137 ( 17 ): 2017 – 39 .

Helsingen LM , Vandvik PO , Jodal HC , Agoritsas T , Lytvyn L , Anderson JC , et al . Colorectal cancer screening with faecal immunochemical test‑ing, sigmoidoscopy or colonoscopy: a clinical practice guideline . BMJ . 2019 ; 367 : l5515 .

Kastrinos F , Kupfer SS , Gupta S . Colorectal cancer risk assessment and precision approaches to screening: brave new world or worlds apart? Gastroenterology . 2023 ; 164 ( 5 ): 812 – 27 .

Chen H , Li N , Shi J , Ren J , Liu C , Zhang Y , et al . Comparative evaluation of novel screening strategies for colorectal cancer screening in China (TARGET‑C): a study protocol for a multicentre randomised controlled trial . BMJ Open . 2019 ; 9 ( 4 ): e025935 .

Chen H , Lu M , Liu C , Zou S , Du L , Liao X , et al . Comparative evaluation of participation and diagnostic yield of colonoscopy vs fecal immuno‑chemical test vs risk‑adapted screening in colorectal cancer screening: interim analysis of a multicenter randomized controlled trial (TARGET‑C) . Am J Gastroenterol . 2020 ; 115 ( 8 ): 1264 – 74 .

Chen H , Shi J , Lu M , Li Y , Du L , Liao X , et al . Comparison of colonoscopy, fecal immunochemical test, and risk‑adapted approach in a colo‑rectal cancer screening trial (TARGET‑C) . Clin Gastroenterol Hepatol . 2023 ; 21 ( 3 ): 808 – 18 .

Lu B , Luo J , Yan Y , Zhang Y , Luo C , Li N , et al . Evaluation of long‑term ben‑efits and cost‑effectiveness of nation‑wide colorectal cancer screening strategies in China in 2020–2060: a modelling analysis . Lancet Reg Health . 2024 ; 51 : 101172 .

The R Foundation . R: The R Project for Statistical Computing . https://www.r‑project.org/ . Accessed 2 Oct 2025 .

Sung JJY , Chiu HM , Lieberman D , Kuipers EJ , Rutter MD , Macrae F , et al . Third Asia‑Pacific consensus recommendations on colorectal cancer screening and postpolypectomy surveillance . Gut . 2022 ; 71 ( 11 ): 2152 – 66 .

Shaukat A , Mongin SJ , Geisser MS , Lederle FA , Bond JH , Mandel JS , et al . Long‑term mortality after screening for colorectal cancer . N Engl J Med . 2013 ; 369 ( 12 ): 1106 – 14 .

Atkin W , Wooldrage K , Parkin DM , Kralj‑Hans I , MacRae E , Shah U , et al . Long term effects of once‑only flexible sigmoidoscopy screening after 17 years of follow‑up: the UK Flexible Sigmoidoscopy Screening randomised controlled trial . Lancet . 2017 ; 389 ( 10076 ): 1299 – 311 .

Buskermolen M , Cenin DR , Helsingen LM , Guyatt G , Vandvik PO , Haug U , et al . Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a microsimulation modelling study . BMJ . 2019 ; 367 : l5383 .

Forsberg A , Westerberg M , Metcalfe C , Steele R , Blom J , Engstrand L , et al . Once‑only colonoscopy or two rounds of faecal immunochemical test‑ing 2 years apart for colorectal cancer screening (SCREESCO): preliminary report of a randomised controlled trial . Lancet Gastroenterol Hepatol . 2022 ; 7 ( 6 ): 513 – 21 .

Randel KR , Schult AL , Botteri E , Hoff G , Bretthauer M , Ursin G , et al . Colo‑rectal cancer screening with repeated fecal immunochemical test versus sigmoidoscopy: baseline results from a randomized trial . Gastroenterol‑ogy . 2021 ; 160 ( 4 ): 1085 ‑ 1096.e5 .

Zhou Y , Li N , Luo J , Chen Y , Zhang Y , Dai M , et al . Participation and yield in multiple rounds of colorectal cancer screening based on fecal immuno‑chemical test: a systematic review and meta‑analysis . Am J Gastroenterol . 2025 ; 120 ( 3 ): 524 – 30 .

Shaukat A , Kaalby L , Baatrup G , Kronborg O , Duval S , Shyne M , et al . Effects of screening compliance on long‑term reductions in all‑cause and colorectal cancer mortality . Clin Gastroenterol Hepatol . 2021 ; 19 ( 5 ): 967 ‑ 975.e2 .

Holme Ø , Løberg M , Kalager M , Bretthauer M , Hernán MA , Aas E , et al . Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: a randomized clinical trial . JAMA . 2014 ; 312 ( 6 ): 606 – 15 .

Holme Ø , Løberg M , Kalager M , Bretthauer M , Hernán MA , Aas E , et al . Long‑term effectiveness of sigmoidoscopy screening on colorectal can‑cer incidence and mortality in women and men: a randomized trial . Ann Intern Med . 2018 ; 168 ( 11 ): 775 – 82 .

Wooldrage K , Robbins EC , Duffy SW , Cross AJ . Long‑term effects of once‑only flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: 21‑year follow‑up of the UK flexible sigmoidoscopy screening randomised controlled trial . Lancet Gastroenterol Hepatol . 2024 ; 9 ( 9 ): 811 – 24 .

Bretthauer M , Løberg M , Wieszczy P , Kalager M , Emilsson L , Garborg K , et al . Effect of colonoscopy screening on risks of colorectal cancer and related death . N Engl J Med . 2022 ; 387 ( 17 ): 1547 – 56 .

Wolf AMD , Fontham ETH , Church TR , Flowers CR , Guerra CE , LaMonte SJ , et al . Colorectal cancer screening for average‑risk adults: 2018 guideline update from the American Cancer Society . CA Cancer J Clin . 2018 ; 68 ( 4 ): 250 – 81 .

Peng L , Weigl K , Boakye D , Brenner H . Risk scores for predicting advanced colorectal neoplasia in the average‑risk population: a systematic review and meta‑analysis . Am J Gastroenterol . 2018 ; 113 ( 12 ): 1788 – 800 .

Carr PR , Weigl K , Edelmann D , Jansen L , Chang‑Claude J , Brenner H , et al . Estimation of absolute risk of colorectal cancer based on healthy lifestyle, genetic risk, and colonoscopy status in a population‑based study . Gastro‑enterology . 2020 ; 159 ( 1 ): 129 ‑ 138.e9 .

Briggs SEW , Law P , East JE , Wordsworth S , Dunlop M , Houlston R , et al . Integrating genome‑wide polygenic risk scores and non‑genetic risk to predict colorectal cancer diagnosis using UK Biobank data: population based cohort study . BMJ . 2022 ; 379 : e071707 .

Barnell EK , Wurtzler EM , La Rocca J , Fitzgerald T , Petrone J , Hao Y , et al . Multitarget stool RNA test for colorectal cancer screening . JAMA . 2023 ; 330 ( 18 ): 1760 – 8 .

Imperiale TF , Porter K , Zella J , Gagrat ZD , Olson MC , Statz S , et al . Next‑generation multitarget stool DNA test for colorectal cancer screening . N Engl J Med . 2024 ; 390 ( 11 ): 984 – 93 .

Zorzi M , Battagello J , Selby K , Capodaglio G , Baracco S , Rizzato S , et al . Non‑compliance with colonoscopy after a positive faecal immuno‑chemical test doubles the risk of dying from colorectal cancer . Gut . 2022 ; 71 ( 3 ): 561 – 7 .

Chen H , Li N , Ren J , Feng X , Lyu Z , Wei L , et al . Participation and yield of a population‑based colorectal cancer screening programme in China . Gut . 2019 ; 68 ( 8 ): 1450 – 7 .

浏览量

Downloads

CSCD

文章被引用时，请邮件提醒。

Submit

工具集

关联资源

Targeting intratumoral bacteria reverses MHC-I suppression and enhances nano-based chemoimmunotherapy in colorectal cancer

Diagnostic efficacy of fecal-based miR-92a for advanced colorectal neoplasia: a prospective multicenter screening trial

Molecular diagnostic approaches for enteric parasites: an issue of relevance for deployed soldiers?

Advanced multifunctional nano-delivery platform focusing on treating diseases related to lipid metabolism via targeted intervention in various lipid metabolic processes

National and subnational burden and causes of anemia in China from 1990 to 2023: findings from the Global Burden of Disease Study 2023