CRC is an expensive disease to treat and by preventing its development, the avoided costs of treatment can be offset against the costs of a screening programme . The cost of population-based screening in public funded healthcare systems is an issue of compelling priority. It is required for screening programmes in order to support appropriate decision-making. Costs of a screening programme include: direct costs, time costs (patients' lost time while receiving screening) and productivity costs (patients' lost productivity). Estimating direct screening costs involves the identification and measurement of the inputs (and their values) that go into performing the specific tasks of screening, and required diagnostic evaluations and treatments. Other factors that contribute to the total cost of secondary prevention programmes are: relevant programme structure and organisation, population compliance, chosen screening schedule and unit costs of screening. The most useful ways to express the opportunity cost of screening are "cost per unit of effectiveness" or "cost per unit of benefit". A widely applied economic evaluation is cost-effectiveness.
A screening is regarded as cost-effective when the incremental cost of obtaining a unit of health effect from screening is compared with no screening below an accepted benchmark. According to international literature, the benchmark value commonly applied to preventive technologies is roughly US $40 000 per added year of life . Furthermore, a screening strategy is considered efficient if there is no alternative that results in more life years gained with equal or less cost. Economic evaluation has regarded screening by FOBT [222, 223], DCBE , flexible sigmoidoscopy [224, 225] and colonoscopy [174, 226]. Results of different cost-effectiveness analysis vary consistently among different models and scenarios.
Screening strategies for CRC seem to be cost-effective compared with no screening [227, 228]. CRC screening compares favourably to other cancer screening strategies (cervical cancer screening and mammographic screening)  or other life-saving treatments such as kidney dialysis or coronary artery bypass surgery . Colorectal screening may have an average cost-effectiveness ratio between US $10 000 and $30 000 per year of life saved, thus below the US $40 000 threshold . From an economic point of view, results indicate that CRC screening should be warranted for the average-risk adult over the age of 50 years until the age of 80 years .
Each alternative can be cost-effective, but it is not easy to indicate which screening approach has the best cost-effectiveness ratio from the societal perspective  because each approach is strongly influenced by unit cost of the exam  and screening schedule .
It has been reported that a flexible sigmoidoscopy performed every 5 years and an annual FOBT are the two most cost-effective screening strategies [229,233, 234]. However, according to other studies, a colonoscopy every 10 years could be the best cost-effective screening strategy [226, 235, 236].
A screening strategy is cost-saving when it results in a net economic saving as well as a saving in years of life . Screening-induced savings are mainly due to the prevention of cancer and therefore represent savings on cancer treatment. According to the literature, flexible sigmoidoscopy CRC screening may result, for a 30 years screening programme, after 35 years, in a net savings of direct healthcare costs .
Decisions about whether to make population screening investments appropriately depend on a variety of factors, some related to and others external to the economic evaluation evidence. All in all, the economic implications of colorectal screening for future research and policymaking are clear: CRC screening in average-risk adults is a good long-term investment for society.
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