6Cost-effectiveness of colorectal cancer screening – An overview
Introduction
The aim of population screening, such as colorectal cancer (CRC) screening, is to discover latent disease in its early stages to treat it adequately before it poses a threat to the individual [1]. As such, screening is a commendable method to fight disease. However, a screening program targets an (apparently) healthy population, and should therefore only be implemented after a careful consideration of both the harms and benefits of such a program. Cost-effectiveness analysis provides a tool to weigh and synthesize benefits, harms and costs of interventions and thus can inform the decision process for adopting population screening. In this paper we provide a brief overview of cost-effectiveness analysis and summarize the evidence on the cost-effectiveness of CRC screening in the average-risk population.
Section snippets
Cost-effectiveness analysis
Cost-effectiveness analysis, a form of decision analysis, is an analytic tool that formally compares the health and economic consequences of different interventions, thereby assisting decision makers to identify the interventions that will yield the greatest health benefits, given their resource constraints [2]. Cost-effectiveness analysis cannot determine which the optimal intervention is, but rather which intervention will provide the greatest health benefits, given the decision maker’s
Determining the balance between costs and benefits
The World Health Organization principles for population screening state that screening should only be implemented when there is a good balance between costs and benefits [1]. Unfortunately there is no universal definition for “good balance” and different institutions may have different assessments of whether the incremental cost of one intervention over another is warranted by the additional benefits it provides. An intervention that provides an additional year of life at an incremental cost of
Cost-effectiveness of CRC screening
Since the demonstration of the efficacy of CRC screening with guaiac FOBT in 1993 [15], the economic impact of population screening for CRC has been evaluated in several cost-effectiveness analyses.
Initiatives to reconcile differences between cost-effectiveness analyses
Two collaborative modelling efforts have been undertaken to identify reasons for differences in effectiveness and cost-effectiveness of CRC screening across models.
Future developments likely to affect the cost-effectiveness of CRC screening
Three factors are likely to greatly influence the cost-effectiveness of CRC screening in the coming years: new CRC screening tests, personalized screening recommendations based on CRC risk and rising CRC treatment costs.
The best test is the test that gets done
The discrepancies in the outcomes of the different cost-effectiveness analyses seem to indicate that no conclusion can be drawn concerning which CRC screening program should be implemented. However, the fact that no strategy emerges across the models as being the most effective or having the best incremental cost-effectiveness ratio suggests that, assuming perfect adherence across all modalities, the differences in life-years gained between strategies are quite small. Indeed, with perfect
The best test is the test that gets done well
Although for any test to be effective it first must be done, there is another important aspect to the effectiveness of any screening program: quality. Efficacy of tests is established in trial settings, and cost-effectiveness analyses are almost always based on estimates from these trials. However, the efficacy of a screening test in a trial setting may differ from its effectiveness in real-world settings. Randomized controlled trials generally have detailed screening and follow-up protocols
Summary
Cost-effectiveness analysis is a useful tool for weighing the costs and benefits of alternative screening programs. Many cost-effectiveness analyses have been performed for CRC screening. All studies show that when compared with no CRC screening, all screening modalities provide additional years of life at a cost that is deemed acceptable by most industrialized nations. However even with standardization of assumptions, no one screening program emerges as the most effective in terms of
Conflict of interest
None.
Acknowledgements
Drs. Lansdorp-Vogelaar and Knudsen are supported in part by Cancer Intervention and Surveillance Modeling Network grants from the National Cancer Institute: (U01-CA-097426 (Lansdorp-Vogelaar), U01-CA-115953 (Lansdorp-Vogelaar), and U01-CA-088204 (Knudsen)).
References (91)
- et al.
On the decision rules of cost-effectiveness analysis
J Health Econ
(1993 Dec) - et al.
Randomised controlled trial of faecal-occult-blood screening for colorectal cancer
Lancet
(1996 Nov 30) - et al.
Randomised study of screening for colorectal cancer with faecal-occult-blood test
Lancet
(1996 Nov 30) - et al.
Colorectal cancer screening: clinical guidelines and rationale
Gastroenterology
(1997 Feb) - et al.
Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology
Gastroenterology
(2008 May) The relative economics of screening for colorectal cancer, breast cancer and cervical cancer
Crit Rev Oncol Hematol
(1999 Nov)- et al.
Colon cancer prevention in Italy: cost-effectiveness analysis with CT colonography and endoscopy
Dig Liver Dis
(2007 Mar) Prevention of colorectal cancer: a cost-effectiveness approach to a screening model employing sigmoidoscopy
Ann Oncol
(1998 Jun)- et al.
Cost-effectiveness analysis of screening by faecal occult blood testing for colorectal cancer in Australia
Aust N Z J Public Health
(1996 Apr) - et al.
Colorectal cancer screening in Australia: An economic evaluation of a potential biennial screening program using faecal occult blood tests
Aust New Zeal J Publ Health
(2004)
Immunochemical faecal occult blood tests are superior to guaiac-based tests for the detection of colorectal neoplasms
Eur J Cancer
Guaiac versus immunochemical tests: faecal occult blood test screening for colorectal cancer in a rural community
Aust N Z J Public Health
Fecal occult blood testing in a general medical clinic: comparison between guaiac-based and immunochemical-based tests
Am J Med
Random comparison of guaiac and immunochemical fecal occult blood tests for colorectal cancer in a screening population
Gastroenterology
The colon - the latest terrain for capsule endoscopy
Dig Liver Dis
Modifiable risk factors for colon cancer
Gastroenterol Clin North Am
Racial and ethnic colorectal cancer patterns affect the cost-effectiveness of colorectal cancer screening in the United States
Gastroenterology
Adjuvant therapy for stage II and III colorectal cancer
Semin Oncol
Wide variation in adenoma detection rates at screening flexible sigmoidoscopy
Gastroenterology
Variation in detection of adenomas and polyps by colonoscopy and change over time with a performance improvement program
Clin Gastroenterol Hepatol
Principles and practice of mass screening for disease
Boletin de la Oficina Sanitaria Panamericana
Public health policy and cost-effectiveness analysis
J Natl Cancer Inst Monogr
Cost-effectiveness analysis, extended dominance, and ethics: a quantitative assessment
Med Decis Making
Visualizing cost-effectiveness analysis
JAMA
How much are Americans willing to pay for a quality-adjusted life year?
Med Care
Efficiency measurement of health care: a review of non-parametric methods and applications
Health Care Manag Sci
Special report: fecal DNA analysis for colon cancer screening
Technol Eval Cent Asses Program Exec Summ
Uptake of faecal occult blood test colorectal cancer screening by different ethnic groups in the Netherlands
Eur J Public Health
Colorectal cancer in Italy: a review of current national and regional practice on screening and treatment
Eur J Health Econ
Colorectal cancer test use from the 2005 National Health Interview Survey
Cancer Epidemiol Biomarkers Prev
Participation in colorectal cancer screening: a review
J Natl Cancer Inst
Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study
New Engl J Med
Screening for colorectal cancer: U.S. preventive services task force recommendation statement
Ann Int Med
Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. preventive services task force
Ann Int Med
As tests evolve and costs of cancer care rise: reappraising stool-based screening for colorectal neoplasia
Aliment Pharmacol Ther
Cost-effectiveness of colorectal cancer screening with computed tomography colonography: the impact of not reporting diminutive lesions
Cancer
The cost-effectiveness of CT colonography in screening for colorectal neoplasia
Am J Gastroenterol
Cost-effectiveness analysis of two strategies for mass screening for colorectal cancer in France
Health Econ
Effect of screening for cancer in the Nordic countries on deaths, cost and quality of life up to the year 2017
Acta Oncol
Cost-effectiveness analysis of fecal occult blood screening for colorectal cancer
Int J Technol Assess Health Care
Population screening for colorectal cancer: the implications of an ageing population
Br J Cancer
Cost-saving analysis of screening colonoscopy in Germany
Z Gastroenterol
Methods and economic considerations: group 1 report. ESGE/UEGF Colorectal Cancer–Public Awareness Campaign. The Public/Professional Interface Workshop: Oslo, Norway, June 20-22, 2003. fulfillment corporate
Endoscopy
Option appraisal of population-based colorectal cancer screening programmes in England
Gut
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