Table 4. Strategies for colorectal cancer screening and diagnosis, by country resource level.

Level of resources	General principles	Diagnostic modality
Basic, low HDI	Capacity building: Establish at risk population, primary prevention strategies, create cancer registry	Barium enema if colonoscopy not available; in emergency situations, may be diagnosed at surgery
Limited, low-medium HDI	Establish capacity for colonoscopy (needed for diagnosis)	Opportunistic screening for those covered by health insurance
	Engage in partnership arrangements with cancer centers to build capacity	Diagnostic colonoscopy (or barium enema) for those with symptoms
	Establish national guidelines
	Build quality assurance for lab testing
Enhanced, medium-high HDI	Join international screening networks	Establish organized screening in high-incidence cities/regions starting at age 50 years in persons at average risk: use annual or biennial sensitive gFOBT or FIT; FS (see text for discussion of interval); or colonoscopy every 10 years
	Provide support to less-well-resourced countries in region	Considerable infrastructure is required to support organized screening, including invitations, recalls, reminders, tracking screening test results, ensuring follow-up of those with an abnormal screening test, etc.
Maximal, very high HDI		National (or jurisdiction-wide) organized screening: starting at age 50 years in persons at average risk: use annual or biennial sensitive gFOBT or FIT; or colonoscopy every 10 years; in those at increased risk because of family history, consider colonoscopy

HDI, Human Development Index. Adapted from Cancer: Disease Control Priorities, Third Edition (Volume 3). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015 Nov 1. Chapter 6. The recommendations are meant to be cumulative: any intervention that is feasible at a lower resource level is also an option at higher resource levels (Produced with permission).