Introduction
In 2005, the Centers for Disease Control and Prevention funded five sites to implement the Colorectal Cancer Screening Demonstration Program (CRCSDP). An evaluation is being conducted that includes a multiple case study. Case study results for the start-up period, the time between initial funding and screening initiation, provide details about the program models and start-up process and reveal important lessons learned.

Methods
The multiple case study includes all five CRCSDP sites, each representing a unique case. Data were collected from August 2005 through September 2006 from documents, observations, and more than 70 interviews with program staff and stakeholders.

Results
Sites differed by geographic service area, screening modality selected, and service delivery structure. Program models were influenced by two factors: preexisting infrastructure and the need to adapt programs to fit local service delivery structures. Several sites modeled program components after their National Breast and Cervical Cancer Early Detection Program. Medical advisory boards convened by all sites provided clinical support for developing program policies and quality assurance plans. Partnerships with comprehensive cancer control programs facilitated access to financial and in-kind resources.

Conclusion
The program models developed by the CRCSDP sites offer a range of prototypes. Case study results suggest benefits in employing a multidisciplinary staff team, assembling a medical advisory board, collaborating with local partners, using preexisting resources, designing programs that are easily incorporated into existing service delivery systems, and planning for adequate start-up time.

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Colorectal cancer is the second leading cause of cancer-related death in the United States (1). Although strong scientific evidence suggests that regular colorectal cancer screening is effective in helping to reduce incidence and mortality from this disease (2), less is known about how to effectively implement colorectal cancer screening in a population-based setting. In this context, the Centers for Disease Control and Prevention (CDC) funded five sites in August 2005 to implement the Colorectal Cancer Screening Demonstration Program (CRCSDP) for a 3-year period and planned an evaluation to assess its feasibility. The five grantee organizations are the Maryland Department of Health and Mental Hygiene, the Missouri Department of Health and Senior Services, the Nebraska Department of Health and Human Services, Stony Brook University Medical Center, and Public Health – Seattle & King County.

Before funding the CRCSDP, CDC used Framework for Program Evaluation in Public Health (3) to develop an evaluation plan with three purposes: 1) understanding program implementation (processes); 2) measuring program effects (outcomes) at the individual client level, and 3) assessing program efficiencies (costs). CDC adopted a goal-based (4), utilization-focused (5) evaluation approach and developed evaluation questions, consistent with the purposes above, for each of eight CRCSDP program goals, which were defined on the basis of the program components. CDC selected three methods to evaluate the CRCSDP: 1) a multiple case study, 2) the collection and analysis of clients’ screening and diagnostic services data, and 3) a costs and cost-effectiveness analysis. CDC is collecting and analyzing data for two distinct periods: 1) program start-up (i.e., the time between initial funding and the initiation of screening services) and 2) screening implementation. This report summarizes case study results for the start-up period, describes the five unique program models and the start-up process, and identifies important lessons learned.