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Colorectal cancer screening for average-risk North Americans: an economic evaluation.

Heitman SJ, Hilsden RJ, Au F, Dowden S, Manns BJ - PLoS Med. (2010)

Bottom Line: Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high.Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive.CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies.

View Article: PubMed Central - PubMed

Affiliation: The Department of Medicine, University of Calgary, Alberta, Canada.

ABSTRACT

Background: Colorectal cancer (CRC) fulfills the World Health Organization criteria for mass screening, but screening uptake is low in most countries. CRC screening is resource intensive, and it is unclear if an optimal strategy exists. The objective of this study was to perform an economic evaluation of CRC screening in average risk North American individuals considering all relevant screening modalities and current CRC treatment costs.

Methods and findings: An incremental cost-utility analysis using a Markov model was performed comparing guaiac-based fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually, fecal DNA every 3 years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. All strategies were also compared to a no screening natural history arm. Given that different FIT assays and collection methods have been previously tested, three distinct FIT testing strategies were considered, on the basis of studies that have reported "low," "mid," and "high" test performance characteristics for detecting adenomas and CRC. Adenoma and CRC prevalence rates were based on a recent systematic review whereas screening adherence, test performance, and CRC treatment costs were based on publicly available data. The outcome measures included lifetime costs, number of cancers, cancer-related deaths, quality-adjusted life-years gained, and incremental cost-utility ratios. Sensitivity and scenario analyses were performed. Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high. Among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,393 [corrected] and the number of CRC deaths from 1,782 [corrected] to 457, while saving CAN$68 per person. Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive.

Conclusions: CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies. Health policy decision makers should consider prioritizing funding for CRC screening using FIT.

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Related in: MedlinePlus

Model bubble diagram.This diagram depicts the general health states and flow through the model.
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pmed-1000370-g001: Model bubble diagram.This diagram depicts the general health states and flow through the model.

Mentions: The Markov model was constructed using decision analysis software (TreeAge Pro Suite 2007). It was assumed that all CRCs arise through the following sequence: normal colon → nonadvanced adenoma → advanced adenoma → CRC. Nonadvanced adenomas were defined as tubular adenomas <10 mm in size. Advanced adenomas comprised any adenoma ≥10 mm regardless of histology, and adenomas <10 mm containing at least 25% villous component and/or high grade dysplasia. We considered several general health states, including (1) alive with no prevalent or prior history of adenomas or CRC, (2) alive with a missed adenoma, (3) alive with a missed asymptomatic CRC, (4) alive with a missed CRC after presenting with symptoms, (5) alive with a CRC found by screening, (6) alive post polypectomy, and (7) dead. Each year (1-y cycle length), individuals with or without adenomas or CRC could either remain in the same health state, progress to another health state, or die (Figure 1).


Colorectal cancer screening for average-risk North Americans: an economic evaluation.

Heitman SJ, Hilsden RJ, Au F, Dowden S, Manns BJ - PLoS Med. (2010)

Model bubble diagram.This diagram depicts the general health states and flow through the model.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2990704&req=5

pmed-1000370-g001: Model bubble diagram.This diagram depicts the general health states and flow through the model.
Mentions: The Markov model was constructed using decision analysis software (TreeAge Pro Suite 2007). It was assumed that all CRCs arise through the following sequence: normal colon → nonadvanced adenoma → advanced adenoma → CRC. Nonadvanced adenomas were defined as tubular adenomas <10 mm in size. Advanced adenomas comprised any adenoma ≥10 mm regardless of histology, and adenomas <10 mm containing at least 25% villous component and/or high grade dysplasia. We considered several general health states, including (1) alive with no prevalent or prior history of adenomas or CRC, (2) alive with a missed adenoma, (3) alive with a missed asymptomatic CRC, (4) alive with a missed CRC after presenting with symptoms, (5) alive with a CRC found by screening, (6) alive post polypectomy, and (7) dead. Each year (1-y cycle length), individuals with or without adenomas or CRC could either remain in the same health state, progress to another health state, or die (Figure 1).

Bottom Line: Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high.Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive.CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies.

View Article: PubMed Central - PubMed

Affiliation: The Department of Medicine, University of Calgary, Alberta, Canada.

ABSTRACT

Background: Colorectal cancer (CRC) fulfills the World Health Organization criteria for mass screening, but screening uptake is low in most countries. CRC screening is resource intensive, and it is unclear if an optimal strategy exists. The objective of this study was to perform an economic evaluation of CRC screening in average risk North American individuals considering all relevant screening modalities and current CRC treatment costs.

Methods and findings: An incremental cost-utility analysis using a Markov model was performed comparing guaiac-based fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually, fecal DNA every 3 years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. All strategies were also compared to a no screening natural history arm. Given that different FIT assays and collection methods have been previously tested, three distinct FIT testing strategies were considered, on the basis of studies that have reported "low," "mid," and "high" test performance characteristics for detecting adenomas and CRC. Adenoma and CRC prevalence rates were based on a recent systematic review whereas screening adherence, test performance, and CRC treatment costs were based on publicly available data. The outcome measures included lifetime costs, number of cancers, cancer-related deaths, quality-adjusted life-years gained, and incremental cost-utility ratios. Sensitivity and scenario analyses were performed. Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high. Among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,393 [corrected] and the number of CRC deaths from 1,782 [corrected] to 457, while saving CAN$68 per person. Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive.

Conclusions: CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies. Health policy decision makers should consider prioritizing funding for CRC screening using FIT.

Show MeSH
Related in: MedlinePlus