Case Studies

Slovakia has one of the highest incidence and mortality rates of colorectal cancer in Europe. While a population-based colorectal screening program was introduced by the Ministry of Health in 2019, participation remained low, and its long-term effectiveness had not been systematically evaluated. To address this gap, a study was conducted to assess the cost-effectiveness of different screening strategies, specifically comparing biennial versus annual faecal immunochemical test (FIT) screening for individuals aged 50–75 years. The study aimed to inform policymakers about the most efficient and feasible colorectal cancer screening approach, contributing to national cancer screening strategies. 

The study used the MISCAN-Colon microsimulation model to compare the cost-effectiveness of the two strategies. The findings demonstrated that both biennial and annual FIT screening are cost-effective compared to no screening, with annual FIT providing greater mortality reduction, although at a higher cost.

The project followed a structured methodology, using national epidemiological data supplemented with external references due to limitations in available data. Additionally, it also considered real-world barriers to implementation, such as healthcare resource constraints and adherence rates.

The study provided strong evidence of the long-term benefits of structured colorectal screening in Slovakia, emphasizing the need for higher participation to maximize effectiveness. However, challenges remain, as low adherence rates and organizational barriers hinder full implementation. Additionally, uncertainties in adherence, screening costs and healthcare capacity may affect scalability. Despite these limitations, the study is a valuable resource for evidence-based policymaking, supporting efforts to optimize colorectal screening in Slovakia.

Enablers: Public health insurance that covered FIT screening, ensuring financial accessibility for eligible individuals (Financing); the Ministry of Health led the transition to organized screening, supported by national guidelines and international research collaborations, and several stakeholders (such as the National Oncology Institute, health insurers, general practitioners, and public health agencies) were involved (Governance); existing laboratory capacity facilitated the processing of FIT samples (Resources); and general practitioners played a role in inviting eligible individuals, increasing awareness and access to screening services (Service Delivery).

Barriers: The lack of stable, earmarked funding for nationwide implementation, affecting long-term sustainability. Limited resources for outreach campaigns and participation incentives contributed to low engagement, while cost variations across providers led to inefficiencies in budget allocation (Financing). Insufficient monitoring and evaluation mechanisms and low transparency in participation rates and screening effectiveness hindered accountability, and the absence of comprehensive cancer registry data since 2011 required reliance on external datasets (Governance). A shortage of trained healthcare professionals, particularly in primary care and endoscopy services, limited follow-up colonoscopy capacity. Geographic disparities in the distribution of specialists created unequal access to diagnostic services, disproportionately affecting certain regions (Resources). Finally, inconsistent GP engagement and limited public awareness campaigns reduced participation. Service integration challenges, particularly between primary care and specialist services, led to delays in diagnostic follow-ups, impacting the effectiveness of screening (Service delivery).

The implementation of colorectal cancer screening in Slovakia has advanced key health system objectives, but significant challenges remain. The study confirmed that both biennial and annual FIT screening strategies are cost-effective, promoting efficient resource allocation. However, disparities in participation, particularly among underserved populations, limit equity. While the shift to organized screening has improved access, low adherence rates reduce its overall impact.

Despite its potential, the program’s success depends on increasing participation, securing stable financing, and strengthening monitoring efforts to align with broader health system goals of reducing the burden of colorectal cancer and improving population health outcomes.

Lessons learned: While the study adhered to its initial plan, gaps in national colorectal cancer epidemiology data required reliance on external sources, highlighting the urgent need for comprehensive cancer registries. Effective screening depends not only on cost-efficiency but also on participation, emphasizing the necessity of targeted awareness campaigns and stronger primary care involvement.

Earlier integration of general practitioners and streamlined follow-up pathways could have enhanced implementation. The study benefited from international collaboration, which provided methodological expertise and reinforced policy recommendations. For other countries, stable funding, systematic data collection and clear governance structures are essential for success. Aligning screening intervals with healthcare capacity and population preferences further improves feasibility. Ultimately, successful CRC screening programs require not only cost-effectiveness but also strategic investment in healthcare infrastructure, workforce training and sustained public engagement to maximize impact.