Colorectal cancer screening program: no health gains without effective implementation and financing

Introduction

Colorectal cancer (CRC) represents the second highest cancer incidence in Portugal. A Colorectal Cancer Screening Program (PRCCR) was implemented in 2019 to achieve early diagnosis. Yet, its effective implementation has never been evaluated.

Objectives

To evaluate PRCCR implementation at a Local Health Unit (ULS), which groups hospitals and primary care centers under a common structure. We characterize new CRC cases diagnosed between 2019 and 2024, and analyse associated costs of the PRCCR implementation with different scenarios.

Methods

Observational, descriptive, retrospective study with cohort analysis. Analysis included 55,338 PRCCR activity records and 245 diagnosed CRC cases. Operational indicator analysis, characterization of new cases and scenario analysis were conducted.

Results

Only 37.9% of records showed valid screening results. Of positive tests, 59.2% were referred for colonoscopy and only 31.0% of requested colonoscopies were performed according to the guidelines. Advanced stages (III/IV) represented 71.1% of cases. Scenario analysis demonstrated that increased participation results in growing losses for ULS, due to increased screening implementation costs and treatment of identified cases, inadequately compensated and incentivized in the current financing model.

Conclusions

Significant operational failures and misalignment between the incentive model and public health objectives were identified, compromising program effectiveness and sustainability.

Key messages

• Colorectal cancer screening in Portugal is critically under-implemented in volume and quality, with significant follow-up losses leading to predominantly late-stage diagnoses.

• Improving screening requires aligned payment incentives, quality metrics, decentralised outreach and operational monitoring to reduce losses and enable long-term health gains.