Variation of colorectal, breast and prostate cancer screening activity in Switzerland: Influence of insurance, policy and guidelines

PLoS One. 2020 Apr 16;15(4):e0231409. doi: 10.1371/journal.pone.0231409. eCollection 2020.


Variation in utilization of healthcare services is influenced by patient, provider and healthcare system characteristics. It could also be related to the evidence supporting their use, as reflected in the availability and strength of recommendations in clinical guidelines. In this study, we analyzed the geographic variation of colorectal, breast and prostate cancer screening utilization in Switzerland and the influence of available guidelines and different modifiers of access. Colonoscopy, mammography and prostate specific antigen (PSA) testing use in eligible population in 2014 was assessed with administrative claims data. We ran a multilevel multivariable logistic regression model and calculated Moran's I and regional level median odds ratio (MOR) statistics to explore residual geographic variation. In total, an estimated 8.1% of eligible persons received colonoscopy, 22.3% mammography and 31.3% PSA testing. Low deductibles, supplementary health insurance and enrollment in a managed care plan were associated with higher screening utilization. Cantonal breast cancer screening programs were also associated with higher utilization. Spatial clustering was observed in the raw regional utilization of all services, but only for prostate cancer screening in regional residuals of the multilevel model. MOR was highest for prostate cancer screening (1.24) and lowest for colorectal cancer screening (1.16). The reasons for the variation of the prostate cancer screening utilization, not recommended routinely without explicit shared decision-making, could be further investigated by adding provider characteristics and patient preference information. This first cross-comparison of different cancer screening patterns indicates that the strength of recommendations, mediated by specific health policies facilitating screening, may indeed contribute to variation.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Breast Neoplasms / diagnosis*
  • Breast Neoplasms / epidemiology
  • Colorectal Neoplasms / diagnosis*
  • Colorectal Neoplasms / epidemiology
  • Early Detection of Cancer / economics
  • Early Detection of Cancer / standards
  • Early Detection of Cancer / statistics & numerical data*
  • Female
  • Humans
  • Insurance, Health
  • Male
  • Mass Screening / economics
  • Mass Screening / standards
  • Mass Screening / statistics & numerical data*
  • Middle Aged
  • Models, Statistical
  • Practice Guidelines as Topic
  • Prostatic Neoplasms / diagnosis*
  • Prostatic Neoplasms / epidemiology
  • Switzerland

Grant support

This work was supported by the SNSF National Research Programme "Smarter Health Care" (NRP 74), project number 26, grant number 407440_167349 (applicant MS, co- applicants VvW and HD, project and funding description available at The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views reported here are of the authors’ and do not necessarily reflect the funding organization. Helsana Group provided support in the form of salaries for authors CB, EB, BB, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.