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Cost-effectiveness of colorectal cancer screening – An overview

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There are several modalities available for a colorectal cancer (CRC) screening program. When determining which CRC screening program to implement, the costs of such programs should be considered in comparison to the health benefits they are expected to provide. Cost-effectiveness analysis provides a tool to do this. In this paper we review the evidence on the cost-effectiveness of CRC screening. Published studies universally indicate 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. Many recent studies even find CRC screening to be cost-saving. However, when the alternative CRC screening strategies are compared against each other in an incremental cost-effectiveness analysis, no single optimal strategy emerges across the studies. There is consensus that the new technologies of stool DNA testing, computed tomographic colonography and capsule endoscopy are not yet cost-effective compared with the established CRC screening tests.

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)).

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