Effects of screening and universal healthcare on long-term colorectal cancer mortality

BACKGROUND: To evaluate the time trends of colorectal cancer (CRC) affected by a Nationwide Colorectal Cancer Screening (NCCS) programme with biennial faecal immunochemical testing (FIT) and Nationwide Healthcare Insurance (NHI). METHODS: Data from the national registries on cancer and death in Taiwan were separated into years 1984–1993, 1994–2003 and 2004–2013 based on the implementations of NHI (starting 1995) and NCCS (starting 2004). The adult population was divided into three age groups (young, 30–49; middle-aged, 50–69; and old, 70–84 years); only the middle-aged were eligible for NCCS. Crude and adjusted effects of NCCS and NHI were quantified by percentage change and 95% confidence interval (CI) with respect to CRC mortality, according to the attributions from incidence and survival. RESULTS: Within 335 million person-years of follow-up, 204 362 incident CRCs and 80 771 CRC-related deaths were identified. Increasing mortality trends were noted for 1994–2003 (post-NHI) vs 1984–1993 due to remarkable increasing incidence trends that could not be offset by improved survival as a result of NHI. During 2004–13 (post-NCCS), mortality continued to increase by 15% (95% CI: 10–21%) in young adults (30–49 years) and 8% (95% CI: 6–11%) in older adults (70–84 years), whereas middle-aged adults (50–69 years) had a reduction of 7% (95% CI: 5–9%) due to a remarkable stage shift and subsequent improvement in survival. In the middle-aged adults, increased incidence was less but survival improvement was more compared with other age groups. CONCLUSIONS: Whereas universal healthcare insurance led to improvement in CRC survival, FIT-based screening has made an even greater contribution to reducing CRC mortality.