Skip to main content
Log in

The dynamics of colorectal cancer management in 17 countries

The European Journal of Health Economics Aims and scope Submit manuscript

Cite this article


This paper discusses the current care management arrangements for colorectal cancer (CRC) in 16 OECD countries plus the Russian Federation by analysing data sources, the uptake of screening and surveillance, the available capacity in endoscopy services, the treatment pathways in medical treatment, as well as the type and availability of pharmaceutical care. The paper highlights significant variations in practice across the 17 countries. Common themes emerge from each of these practices and standards in terms of political interest in policies and awareness of CRC (both of which need to be enhanced), affordability (in terms of scarcity of resources in some countries and out-of-pocket payments for parts of the overall treatment process), access (in terms of the significant variation that has been observed within and across countries with regard to diagnostics, treatment and certain pharmaceuticals) and quality of CRC services (which may arise due to variations in treatment and pharmaceutical guidelines as well as minimal monitoring). When considering policy options for the future, it is important to, first, improve data collection both within as well as across countries through international co-operation; second, it is critical to have greater national and international support for cancer screening activities proven to be effective and cost-effective; third, endoscopy capacity in individual countries needs to be improved, also allowing more choice to ensure timely diagnosis, regardless of screening activities; fourth, public and political awareness needs to be enhanced as it is the key to improving CRC outcomes; fifth, where appropriate, to give consideration to the principles of equity, human dignity and disease severity, among others, when deciding on the uptake of new (targeted) treatments, rather than base decisions solely on cost-effectiveness criteria; and sixth, to firm up national guidelines including screening, diagnosis, treatment, pharmaceutical treatments and surveillance, with a view to enhancing their timeliness, evidence-base and free access to all.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others


  1. Cancer and CRC incidence and mortality were chosen as proxies for country cancer population burdens. In countries with particularly poor-quality cancer registry data (Hungary, Russia) these estimates may be less accurate; however, for the remaining countries this correction gives an estimate of cancer spending per incident (first year of cancer) and mortality (last year of cancer) when spending is likely to be the highest.


  1. Ferlay, J., Autier, P., Boniol, M., et al.: Estimates of the cancer incidence and mortality in Europe in 2006. Ann. Oncol. (2007)

  2. Verdecchia, A., Francisci, S., Brenner, H., et al.: Recent cancer survival in Europe: a 2000–2002 period analysis of EUROCARE-4 data. Lancet Oncol. (2007)

  3. Sant, M., Aereleid, T., Berrino, F., et al.: EUROCARE-3: survival of cancer patients diagnosed 1990–1994—results and commentary. Ann. Oncol. 14(S5), v61–118 (2003)

    Google Scholar 

  4. Streetly, A, Holland, W.: Population screening and public health. In: Oxford Textbook of Public Health, vol. 3, chapter 12.7. Oxford University Press (2009)

  5. Gatta, G., Ciccolallo, L., Capocaccia, R., et al.: Differences in colorectal cancer survival between European and US populations: the importance of sub-site and morphology. Eur. J. Cancer 39, 2214–2222 (2003)

    Article  Google Scholar 

  6. Council of the European Union: Council recommendation of 2 December 2003 on cancer screening. Official J. EU 327, 34–38 (2003)

    Google Scholar 

  7. Europe against Colorectal Cancer: Declaration of Brussels (2007). Accessed Jun 2009

  8. European Group for Colorectal Screening: Recommendation to include colorectal cancer screening in public health policy. J. Med. Screen. 6, 80–81 (1999)

    Google Scholar 

  9. Perry, N., Broeders, M., de Wolf, C., et al. (eds.): European guidelines for quality assurance in breast cancer screening and diagnosis, 4th edn. Office for Official Publications of the European Communities, Luxembourg (2006)

    Google Scholar 

  10. Kanavos, P., Schurer, W., Owusu-Apenten, C., et al.: Colorectal cancer in Europe and Australia: challenges and opportunities for the future. London School of Economics, LSE Health, London (2008)

    Google Scholar 

  11. European Commission: Cancer screening in the European Union: report on the implementation of the council recommendation on cancer screening—first report. Brussels (2008)

  12. Australian Institute of Health and Welfare, Australian Government Department of Health and Aging for the National Bowel Cancer Screening Program: National bowel cancer screening program monitoring report 2007. Cancer series, number 40, Canberra (2008)

  13. Gyrd-Hansen, D., Sogaard, J., Kronborg, O.: Colorectal cancer screening: efficiency and effectiveness. Health Econ. 7, 9–20 (1998)

    Article  Google Scholar 

  14. Lejeune, C., Arveux, P., Dancourt, V., et al.: Cost effectiveness analysis of fecal occult blood screening for colorectal cancer. Int. J. Tech. Assoc. Health Care 20, 434–439 (2004)

    Google Scholar 

  15. Berchi, C., Bouvier, V., Réaud, J.M.: Cost effectiveness analysis of two strategies for mass screening for colorectal cancer in France. Health Econ. 13, 227–238 (2004)

    Article  Google Scholar 

  16. Stone, C.A., Carter, R.C., Vos, T., et al.: Colorectal cancer screening in Australia: an economic evaluation of a potential biennial screening program using faecal occult blood tests. Aust. N. Z. J. Public Health 28, 273–282 (2004)

    Google Scholar 

  17. Whynes, D.K., Neilson, A.R., Walker, A.R., et al.: Faecal occult blood screening for colorectal cancer: is it cost-effective? Health Econ. 7, 21–29 (1998)

    Article  Google Scholar 

  18. Whynes, D.K., Nottingham, F.O.B.: Screening trial: cost-effectiveness of screening for colorectal cancer: evidence from the Nottingham faecal occult blood trial. J. Med. Screen. 11, 11–15 (2004)

    Article  Google Scholar 

  19. Tappenden, P., Chilcott, J., Eggington, S., et al.: Option appraisal of population based colorectal cancer screening programmes in England. Gut 56, 677–684 (2007)

    Article  Google Scholar 

  20. O’Leary, B.A., Olynyk, J.K., Neville, A.M., et al.: Cost-effectiveness of colorectal cancer screening: comparison of community-based flexible sigmoidoscopy with fecal occult blood testing and colonoscopy. J. Gastroenterol. Hepatol. 19, 38–47 (2004)

    Article  Google Scholar 

  21. Norum, J.: Prevention of colorectal cancer: a cost-effectiveness approach to a screening model employing sigmoidoscopy. Ann. Oncol. 9, 613–618 (1998)

    Article  Google Scholar 

  22. Hassan, C., Zullo, A., Laghi, A., et al.: Colon cancer prevention in Italy: Cost-effectiveness analysis with CT colonography and endoscopy. Dig. Liver Dis. 39, 242–250 (2007)

    Google Scholar 

  23. Denis, B.J., Ruetsch, M., Strentz, P., et al.: Short term outcomes of the first round of a pilot colorectal cancer screening programme with guaiac based faecal occult blood test. Gut 56, 1579–1584 (2007)

    Article  Google Scholar 

  24. Bowel Cancer UK: The bowel cancer screening programme: a progress report on the roll-out of screening in England ( (2007). Accessed August 2009

  25. Segnan, N., Senore, C., Androni, B., et al.: Randomized trial of different strategies for colorectal cancer: patient response and detection rates. J. Natl Cancer Inst. 97, 347–357 (2005)

    Google Scholar 

  26. UK Flexible Sigmoidoscopy Screening Trial Investigators: Single flexible sigmoidoscopy screening to prevent colorectal cancer: baseline findings of a UK muticentre randomised trial. Lancet 359, 1291–1300 (2002)

    Article  Google Scholar 

  27. Zorzi, M., Falcini, F., Fedato, C., et al.: Screening for colorectal cancer in Italy: 2006 survey. Epidemiol. Prev. 32(S1), 55–68 (2008)

    Google Scholar 

  28. European Commission: Health in the European Union. Special Eurobarometer 272e/Wave 66.2 (2007)

  29. Geitona, M., Kanavos, P.: Colorectal cancer management and prevention policies in Greece (this issue)

  30. Verastegui, E., Mohar, A.: Colorectal cancer in Mexico: should a middle income country invest in screening or treatment? (this issue)

  31. Avkentieva, M.: Colorectal cancer in Russia (this issue)

  32. Tatar, M., Tatar, F.: Colorectal cancer in Turkey: current situation and challenges for the future (this issue)

  33. Chevreul, K.: Colorectal cancer in France (this issue)

  34. Masseria, C.: Colorectal cancer in Italy: a review of current national and regional practices on screening and treatment (this issue)

  35. Schurer, W., Kanavos, P.: Evolution of colorectal cancer care in the United Kingdom (this issue)

  36. Schulenburg, M.G., Prenzler, A., Schurer, W.: Cancer management and reimbursement aspects in Germany—an overview of colorectal cancer (this issue)

  37. Ruszkowski, J.: Colorectal cancer in Poland: undergoing improvements (this issue)

  38. Pinto, C.G., Paquete, A.T., Pissarra, I.: Colorectal cancer in Portugal (this issue)

  39. Schurer, W.: The current status of colorectal cancer in the Netherlands: directions to the future (this issue)

  40. Lopez-Bastida, J., Bellas-Beceiro, B., Quintero-Carrión, E.: The challenge of colorectal cancer prevention in Spain (this issue)

  41. Boncz, I., Brodszky, V., Péntek, M., Ágoston, I., Nagy, Z., Kárpáti, K., Kriszbacher, I., Fuszek, P., Gulácsi, L.: The disease burden of colorectal cancer in Hungary (this issue)

  42. Vrangbaek, K., Nielsen, M.B.: Colorectal cancer care in Denmark: status and dilemmas (this issue)

  43. Canard, J.M., Debette-Gratien, M., Dumas, R., et al.: A prospective national study on colonoscopy and sigmoidoscopy in 2000 in France. Gastroenterol. Clin. Biol. 29, 17–22 (2005)

    Google Scholar 

  44. National Health Service: Cancer screening programmes. Accessed Jul 2009

  45. Terhaar sive Droste, J.S., Craanen, M.E., Kolkman, J.J., et al.: Dutch endoscopic capacity in the era of colorectal screening. Neth. J. Med. 64, 371–374 (2006)

    Google Scholar 

  46. Price, J., Campbell, C., Sells, J., et al.: Impact of UK colorectal cancer screening pilot on hospital diagnostic services. J. Public Health 27, 246–253 (2005)

    Article  Google Scholar 

  47. Weller, D., Coleman, D., Robertson, R., et al.: The UK colorectal cancer screening pilot: results of the second round of screening in England. Br. J. Cancer 97, 1601–1605 (2007)

    Article  Google Scholar 

  48. Fernando, S.A., Duggan, A.E., Dent, O.F., et al.: Colonoscopy capacity in selected New Shouth Wales hospitals. Med. J. Aust. 187, 249–250 (2007)

    Google Scholar 

  49. Bowles, C.J.A., Leicester, R., Romaya, C., et al.: A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut 53, 277–283 (2004)

    Article  Google Scholar 

  50. Macrae, F.A.: Providing colonoscopy services for the National Bowel Cancer Screening Program. MJA 186, 280–281 (2007)

    Google Scholar 

  51. Shapero, T., Hoover, J., Paszat, L.F., et al.: Colorectal cancer screening with nurse-performed flexible sigmoidoscopy: results from a Canadian community-based program. Gastrointest. Endosc. 65, 640–645 (2007)

    Article  Google Scholar 

  52. Coebergh, J.W.W.: Challenges and pit-falls of mass screening in the European Union. Eur. J. Cancer 36, 1469–1472 (2000)

    Article  Google Scholar 

  53. Coebergh, J.W.W.: Colorectal cancer screening in Europe: first things first. Eur. J. Cancer 40, 638–642 (2004)

    Article  Google Scholar 

  54. French National Society of Gastroenterology. Thesaurus for digestive cancers (Translated from French). (2009). Accessed August 2009

  55. Standards, Options and Recommendations. Palliative chemotherapy in patients with metastatic colorectal cancer (Translated from French). +colorectal&file=APC_DIG_Colorectale-Chimio_int.pdf (2003). Accessed August 2009

  56. Standards, Options and Recommendations. Perioperative chemotherapy in patients with resectable rectal cancer (Translated from French). (2007). Accessed August 2009

  57. German Oncology Association. S3 Guidelines for Colorectal Cancer (Translated from German). (2008). Accessed August 2009

  58. Standards, Options and Recommendations. Recommendations for palliative chemotherapy for patients with metastatic colorectal cancer (Translated from French). (2005). Accessed August 2009

  59. Schmiegel, W., Pox, C., Reinacher-Schick, A., et al.: S3-guideline “colorectal cancer” (2004/2008). Accessed Jul 2009

  60. Italian Medical Oncology Association (AIOM). Guidelines for the treatment of colorectal cancer (Translated from Italian).,348,0 (2007). Accessed August 2009

  61. Oncoline. National working group on gastrointestinal tumours (Translated from Dutch). (2008). Accessed August 2009

  62. National Institute for Health and Clinical Excellence: Improving outcomes in colorectal cancers. (2004). Accessed August 2009

  63. National Institute for Health and Clinical Excellence: Guidance on the use of capecitabine and tegafur with uracil for metastatic colorectal cancer. NICE Technology Appraisal 61. (2003). Accessed August 2009

  64. National Institute for Health and Clinical Excellence: Capecitabine and oxaliplating in the adjuvant treatment of stage III colon cancer. NICE Technology Appraisal 100. (2006). Accessed August 2009

  65. National Institute for Health and Clinical Excellence: Irintotecan, oxaliplatin and raltitrexed for the treatment of advanced colorectal cancer. NICE Technology Appraisal 93. (2005). Accessed August 2009

  66. National Institute for Health and Clinical Excellence: Bevacizumab and cetuximab for the treatment of metastatic colorectal cancer. NICE Technology Appraisal 118. (2007). Accessed August 2009

  67. National Institute for Health and Clinical Excellence: Laparoscopic surgery for colorectal cancer. NICE Technology Appraisal Guidance 105. (2006). Accessed August 2009

  68. European Society Medical Oncology Working Group: Colon cancer: ESMO clinical recommendations for diagnosis adjuvant treatment and follow-up. Ann. Oncol. 18(S2), ii21–22 (2007)

    Google Scholar 

  69. Danish Colorectal Cancer Association: Guidelines for diagnosis and treatment of colorectal cancer (2005). Accessed July 2009

  70. European Society Medical Oncology Working Group: Advanced colorectal cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann. Oncol. 18(S2), ii25–26 (2007)

    Google Scholar 

  71. European Society Medical Oncology Working Group: Rectal cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann. Oncol. 18(S2), ii23–24 (2007)

    Google Scholar 

  72. National Comprehensive Cancer Network: NCCN clinical practice guidelines in oncology: colon cancer. V.1.2008 Accessed Jul 2009

  73. National Comprehensive Cancer Network: NCCN clinical practice guidelines in oncology: rectal cancer. V.1.2008 Accessed Jul 2009

  74. National Comprehensive Cancer Network: Colon and rectal cancer: treatment guidelines for patients. Version V (2007)

  75. Bisschops, R., Wilmer, A., Tack, J.: A survey on gastroenterology training in Europe. Gut 50, 724–729 (2002)

    Article  Google Scholar 

  76. Rivera, P., Delorg, J.P., Grosclaude, P., et al.: French medical demography in oncology: demographic futurology for the next 30 years. Bull. Cancer 91, 271–277 (2004)

    Google Scholar 

  77. Ruiter, D.J., Roald, B., Underwood, J., et al.: Histopathology training in Europe: a lesson for other specialties? Virchows Arch. 444, 278–282 (2004)

    Article  Google Scholar 

  78. GLOBOCAN (2002). Accessed Jul 2009

  79. Ciccolallo, L., Capocaccia, R., Coleman, M.P., et al.: Survival differences between European and US patients with colorectal cancer: role of stage at diagnosis. Gut 54, 268–273 (2005)

    Article  Google Scholar 

  80. Bouhier, K., Maurel, J., Lefevre, H., et al.: Changing practices for diagnosis and treatment of colorectal cancer in Calvados: 1990–1999. Gastroenterol. Clin. Biol. 28, 371–376 (2004)

    Article  Google Scholar 

  81. de Leon, M.P., Pezzi, A., Benatti, P., et al.: Survival, surgical management and perioperative mortality of colorectal cancer in the 21-year experience of a specialised registry. Int. J. Colorectal Dis. 24, 777–788 (2009)

    Article  Google Scholar 

  82. Manfredi, S., Benhamiche, A.M., Meny, B., et al.: Population-based study of factors influencing occurrence and prognosis of local recurrence after surgery for rectal cancer. Br. J. Surg. 88, 1221–1227 (2001)

    Article  Google Scholar 

  83. Evans, H.S., Moller, H., Robinson, D., et al.: The risk of subsequent primary cancers after colorectal cancer in southeast England. Gut 50, 647–652 (2002)

    Article  Google Scholar 

  84. Bouvier, A.M., Latournierie, M., Jooste, V., et al.: The lifelong risk of metachronous colorectal cancer justifies long-term colonoscopic follow-up. Eur. J. Cancer 44, 522–527 (2008)

    Article  Google Scholar 

  85. Guyot, F., Faivre, J., Manfredi, S., et al.: Time trends in the treatment and survival of recurrences from colorectal cancer. Ann. Oncol. 16, 756–761 (2005)

    Article  Google Scholar 

  86. Clerc, L., Jooste, V., Lejeune, C., et al.: Cost of care of colorectal cancers according to health care patterns and stage at diagnosis in France. Eur. J. Health Econ. (2007)

  87. Australian Cancer Network Colorectal Cancer Guidelines Revision Committee: Guidelines for the prevention, early detection and management of colorectal cancer. The Cancer Council Australia and Australian Cancer Network, Sydney. (2005). Accessed August 2009

Download references


We are grateful to Walter Holland and Richard Sullivan for providing extremely useful comments and insights to earlier versions of the paper, particularly on aspects of screening and surveillance; and to Candida Owusu-Apenten for research assistance. All outstanding errors are our own.

Conflict of interest statement

The authors do not report any conflict of interest associated with this paper.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Panos Kanavos.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Kanavos, P., Schurer, W. The dynamics of colorectal cancer management in 17 countries. Eur J Health Econ 10 (Suppl 1), 115–129 (2010).

Download citation

  • Published:

  • Issue Date:

  • DOI:


JEL Classification