Colorectal Screening in Germany

An annual gFOBT above age 44 had been part of the national cancer screening program in Germany since 1976. This screening was free of charge. Apart from measuring attendance rates, there was no formal evaluation of the screening results so that the efficacy of the program was unknown. Compliance was poor, with only 14 % of eligible men and 34 % of eligible women taking part. In October 2002, this screening program was updated to incorporate CRC-screening using colonoscopy. The new program includes an annual gFOBT between age 50 and 54. The age at which CRC-screening begins was increased to 50 as it was felt that starting earlier was unlikely to be cost-effective. Anyone above age 55 is entitled to a screening colonoscopy, which, if negative, can be repeated once after 10 years. Anyone 55 and older who is unwilling to undergo colonoscopy can continue FOBT biennually. The costs for screening are covered by the health insurance companies which cover more than 90 % of the population (the rest have private insurance which will also pay for screening colonoscopies). To ensure a high quality program, licences for performing screening colonoscopies are limited to endoscopists who have performed more than 200 colonoscopies and 50 polypectomies within the last two years. In order to maintain the license, 200 colonoscopies and 10 polypectomies are required annually. Numbers and completeness of exams are checked by regional bodies. Infection control measures include annual external microbiological testing of colonoscopies. The completeness of colonoscopy (cecum), findings and acute complications (self reporting) of every screening colonoscopy have to be documented by the endoscopist. Otherwise there is no reimbursement for the examination (”no cecum, no money”). The documentation was initially done on paper and was replaced by an online form this year. These forms including the histological results are centrally evaluated.

Up to January 2007, more than 2.2 million screening colonoscopies have been performed. An evaluation is available for exams up to December 2005. Between 2002 and 2005, 1.7 million screening colonoscopies were performed i. e. a cumulative attendance rate of 10.2 % of all eligible women and 8.8 % of all eligible men between ages 55 and 74. The average age of screenees was 65.1 years for men and 64.5 years for women. The majority of colonoscopies were performed using sedation (86.4 %). Colorectal cancer was diagnosed in 0.8 %, the majority in an early tumor stage (UICC I 45.1 %, UICC II 23.0 %, UICC III 21.3 %, UICC IV 10.6 %). Adenomas were found in 20.4 %, with a higher detection rate in men than in women. Advanced adenomas (adenomas ≥ 10 mm, high-grade dysplasia, villous histology) were detected in 6.6 % of patients, again with a higher detection rate in men (8.6 %) than in women (5.0 %). In both sexes there was an age-dependent increase in incidence of advanced adenomas. Complications were documented in 1177 patients in 2003 (3.9 / 1000 colonoscopies) and 1494 patients in 2004 (2.8 / 1000 colonoscopies) and 1379 patients in 2005 (2.7 / 1000 colonoscopies including a perforation rate of 3 / 10 000 colonoscopies. Four deaths occurred that were related to the exam. There are 1759 endoscopic sites performing screening colonoscopies, the vast majority ( > 99 %) of which are private practices and not hospital based. In order to be able to evaluate the effect of screening colonoscopy on colorectal cancer incidence and mortality, a prospective study has started in one of the states of Germany (Saarland) with a high-quality cancer registry.

The number of FOBT performed has dropped sharply since introduction of the new program from more than 8.2 million in 2001 to 4.5 million in 2005. It is unclear to what extent this drop was caused by the introduction of colonoscopy screening, the age increase from 45 to 50 years at which FOBT screening starts and the biennual testing after 55.

A recent cost analysis showed that a colonoscopy screening program in Germany is cost effective and could actually result in net savings due to prevention of cancer treatment costs compensating for the costs of screening, surveillance and adverse effects.

In summary, the results of the German colonoscopy program are promising with a high detection rate of neoplasia and a low complication rate. However, about 90 % of the eligible population have not undergone screening colonoscopy, showing that major efforts are required to improve compliance. Persons who are unwilling to undergo screening colonoscopy should be offered FOBT as an alternative method.