Table 2 Top 10 Challenges and opportunities for the implementation of CRC screening programmes in LMICs

 Lack of (cancer registry) data, poor reporting of CRC data [67,68,69,70,71]

Cancer registries have not been established in many LMICs and reporting of cancer-related information is often not mandated. Reliable data on CRC incidence, mortality and screening is therefore often lacking. This leads to and underrepresentation of the cancer problem in LMICs and as a result, lack of funding.

 Low level of CRC knowledge (general population) [67, 69, 72,73,74]

The general public lacks awareness about CRC, CRC screening and the importance of early detection of CRC.

 Inadequate (i) number of trained staff and (ii) staff training [72, 73, 75,76,77]

Lack of specialised staff (e.g. endoscopists, oncologists, radiotherapists, gastroenterologists) and lack of specialised training opportunities leading to lack of appointments for screening and treatment.

 Poor health care system infrastructure [67, 68, 77, 78]

Screening services are not widely available and there are long-waiting times for colonoscopies and endoscopies. There is a lack of screening equipment and structural deficiencies including screening centres. It can also be difficult to travel to services for patients who live in rural areas.

 Lack of organised screening and absence of screening guidelines or poor uptake and use of guidelines [68, 72, 75, 79]

Lack of organised screening programmes/screening guidelines. Some regions completely lack access to CRC screening at primary care level.

 Health policy agenda - CRC not prioritised [72, 73, 75, 79, 80]

Other health services are prioritised over CRC screening in countries where incidence is low. The relatively low importance ascribed to CRC is due partly to an underestimation of the problem of CRC (due to lack of data) as well as other, often communicable, conditions taking priority.

 Low level of CRC knowledge and procedures among medical staff [68, 72, 74, 78, 80]

Low level of awareness among physicians about CRC and poor implementation of screening guidelines.

 Inadequate financial resources [67, 73, 74, 80, 81]

Lack of funding to improve infrastructure and access to screening programmes, staff, centres, treatment, etc.

 Cost to patients [68, 69, 74, 78]

Cost can be a barrier where screening and cancer treatment expenses need to be covered by patients (challenge to make CRC screening widely accessible)

 Insufficient public health campaigns [68, 73, 79, 80]

Lack of CRC awareness raising activities and information about CRC in general likely contributes to low public awareness.

 Improve reporting of CRC screening efforts and evaluation [67, 72, 73]

Establish timely, reliable and efficient health information system for the design, management and evaluation of CRC prevention activities. Implement electronic medical records to allow for ICD-10 coding. Set up a cancer registry where there is none.

 Cost-effective CRC screening methods [67, 74, 80, 81]

Identify cost-effective, culturally-acceptable CRC screening methods and conduct cost-effectiveness evaluation of services to understand impact of services and improve existing practice.

 Improve health care infrastructure [67, 69, 76, 80]

Improve and align infrastructure, improve equitable distribution of screening technology throughout regions

 Increase number of trained endoscopists and provide specialised training to health care staff [67, 70, 80]

Train specialised staff to conduct screening. Options are to train individuals from other specialities and non-physicians to deliver services and to provide e-training. Improved /annual standardised training should also be delivered for personnel who are already practicing.

 Prioritise screening for high risk population [68, 74, 81]

Improve collection of family history and other information related to high-risk of CRC. Screen population at high-risk to better utilise resources and improve awareness on screening guidelines by family history/ high-risk.

 Commitment from governments [67, 69, 70]

Committed, coordinated and comprehensive approach to make CRC a public health priority. One option is bulk purchasing of screening tests from governments so that procedures can be streamlined, costs reduced and efficiency increased

 Awareness programmes for the public and HCPs [74, 78, 80]

Improve CRC awareness among HCPs and patients through for example CRC awareness campaigns/ programmes

 Improve planning of CRC screening programmes, guidelines and policies [69, 73, 74]

The increasing CRC incidence is demanding better programmes. Establish national screening programmes, guidelines for CRC screening/ organized screening strategy and establish cancer control planning through dedicated agencies/ NGOs and/or government.

 Patient navigation and communication with HCPs to improve adherence to screening programmes [70, 76, 80, 81]

Utilize patient navigation; review positive result letter to improve colonoscopy compliance; improve communication about CRC risk and the importance of early screening and follow-up screening/ treatment (colonoscopy) to improve compliance rates

 Improve quality assurance of screening services [73, 76]

Improve programme quality control, quality assurance to ensure optimal impact and improve the quality of health care services