Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis

doi:10.1016/j.gie.2013.10.026

Gastrointestinal Endoscopy

Volume 79, Issue 3, March 2014, Pages 455-465

https://doi.org/10.1016/j.gie.2013.10.026 Get rights and content

Background

Recent studies report that the risk of colorectal cancer (CRC) among patients with ulcerative colitis (UC) may be lower than previously estimated. Although white-light endoscopy (WLE) with random biopsies is recommended for dysplasia detection in patients with UC, several studies reported increased detection of dysplasia by chromoendoscopy.

Objective

To analyze the cost effectiveness of chromoendoscopy relative to WLE or no endoscopy for CRC surveillance in patients with UC.

Design

Decision–analytic state–transition (Markov) model with Monte Carlo simulation.

Setting

To simulate the clinical course of chronic UC, we estimated dysplasia and CRC incidence and progression, endoscopic test characteristics, stage-specific mortality rates, and costs from published literature and Medicare reimbursement data.

Patients

Patients from a population-based age distribution with ulcerative colitis for ≥8 years.

Intervention

We compared 3 different strategies at various surveillance intervals: chromoendoscopy with targeted biopsies, WLE with random biopsies, and no surveillance. The robustness of the model was assessed by using probabilistic sensitivity analysis. One-way sensitivity analyses were performed to evaluate individual variables, and 3-dimensional analysis was used to examine the effects of varying screening intervals.

Main Outcome Measurements

Incremental cost-effectiveness ratio (ICER).

Results

Chromoendoscopy was found to be more effective and less costly than WLE at all surveillance intervals. However, compared with no surveillance, chromoendoscopy was cost effective only at surveillance intervals of at least 7 years, with an ICER of $77,176. Chromoendoscopy was the most cost effective strategy at sensitivity levels >0.23 for dysplasia detection and cost <$2200, regardless of the level of sensitivity of WLE for dysplasia detection. The estimated population lifetime risk of developing CRC ranged from 2.5% (annual chromoendoscopy) to 5.9% (chromoendoscopy every 10 years).

Limitations

Estimates used for the model are based on best available data in the literature.

Conclusion

Chromoendoscopy is both more effective and less costly than WLE and becomes cost effective relative to no surveillance when performed at intervals of ≥7 years.

Section snippets

Model design

We created a decision–analytic state–transition (Markov) model with Monte Carlo simulation by using TreeAge Pro 2009 (TreeAge, Williamstown, Mass). Patients could enter 1 of 3 pathways: no surveillance (natural history), WLE, or chromoendoscopy. Health states included chronic UC, chronic UC with dysplasia, post-colectomy, CRC, and death (Fig. 1). Possible causes of death included baseline mortality or mortality related to colonoscopy, surgery, or CRC. The Markov cycle length was 1 year. The

Base-case analyses

Our primary cost-effectiveness analysis showed that annual chromoendoscopy and WLE were dominated by no surveillance, and the ICER for biennial chromoendoscopy relative to no surveillance was cost prohibitive in the setting of updated CRC estimates among patients with UC (Table 2). By using a WTP threshold of $100,000 per QALY, chromoendoscopy became cost effective only at a surveillance interval of 7 years, with an ICER of $77,176 (Table 2). In a competing strategy analysis, in which we

Discussion

Our analysis indicates that chromoendoscopy is more effective and less costly than WLE for CRC surveillance in patients with UC but becomes cost effective only compared with no surveillance at surveillance intervals of at least 7 years, with a resultant ICER of less than a WTP threshold of $100,000 per QALY. After accounting for lower CRC incidence rates among patients with chronic UC, CRC surveillance every 1 to 2 years does not appear to be cost effective. To our knowledge, this is the first

References (46)

F.A. Farraye et al.
AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease
Gastroenterology
(2010)
G.C. Nguyen et al.
Medical decision analysis for the management of unifocal, flat, low-grade dysplasia in ulcerative colitis
Gastrointest Endosc
(2009)
L.J. Herrinton et al.
Incidence and mortality of colorectal adenocarcinoma in persons with inflammatory bowel disease from 1998 to 2010
Gastroenterology
(2012)
T. Jess et al.
Risk of colorectal cancer in patients with ulcerative colitis: a meta-analysis of population-based cohort studies
Clin Gastroenterol Hepatol
(2012)
C.E. Rubin et al.
DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis
Gastroenterology
(1992)
D.T. Rubin et al.
Are dysplasia and colorectal cancer endoscopically visible in patients with ulcerative colitis?
Gastrointest Endosc
(2007)
M.D. Rutter et al.
Thirty-year analysis of a colonoscopic surveillance program for neoplasia in ulcerative colitis
Gastroenterology
(2006)
A. Kohn et al.
Surgical and nonsurgical hospitalization rates and charges for patients with ulcerative colitis in Italy: a 10-year cohort study
Dig Liver Dis
(2012)
S. de Silva et al.
Postoperative complications and mortality following colectomy for ulcerative colitis
Clin Gastroenterol Hepatol
(2011)
E.B. Schneider et al.
Patient readmission and mortality after colorectal surgery for colon cancer: impact of length of stay relative to other clinical factors
J Am Coll Surg
(2012)

D.A. Fisher et al.

Complications of colonoscopy

Gastrointest Endosc

(2011)

A.J. Muir et al.

A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis

Am J Gastroenterol

(2001)

R.M. Ness et al.

Utility valuations for outcome states of colorectal cancer

Am J Gastroenterol

(1999)

K. Lang et al.

Lifetime and treatment-phase costs associated with colorectal cancer: evidence from SEER-Medicare data

Clin Gastroenterol Hepatol

(2009)

L.M. Wong Kee Song et al.

Chromoendoscopy

Gastrointest Endosc

(2007)

C. Hassan et al.

Cost-effectiveness of early colonoscopy surveillance after cancer resection

Dig Liver Dis

(2009)

T. Ullman et al.

Progression of flat low-grade dysplasia to advanced neoplasia in patients with ulcerative colitis

Gastroenterology

(2003)

D.A. Lieberman et al.

Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer

Gastroenterology

(2012)

M. Pellise et al.

Narrow-band imaging as an alternative to chromoendoscopy for the detection of dysplasia in long-standing inflammatory bowel disease: a prospective, randomized, crossover study

Gastrointest Endosc

(2011)

T. Jess et al.

Decreasing risk of colorectal cancer in patients with inflammatory bowel disease over 30 years

Gastroenterology

(2012)

T.A. Ullman

Should chromoendoscopy be the standard of care in ulcerative colitis dysplasia surveillance?

Gastroenterol Hepatol (NY)

(2010)

J.H. Rubenstein et al.

Cost effectiveness of ulcerative colitis surveillance in the setting of 5-aminosalicylates

Am J Gastroenterol

(2009)

J.A. Eaden et al.

The risk of colorectal cancer in ulcerative colitis: a meta-analysis

Gut

(2001)

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Screening for breast, cervical, and colorectal cancer is recommended in many countries. Economic evaluations have suggested that cancer screening programs are cost effective and sometimes even cost saving.1–10 Economic evaluations are important tools to support decision making in health care by identifying the most efficient way of deploying healthcare resources using the incremental cost–effectiveness ratio (ICER) as the main outcome.11
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The impact of quality of life losses and healthcare expenditures of competing risks in life years gained incurred owing to screening were the highest for breast cancer and the lowest for cervical cancer. The updates suggest that incremental cost-effectiveness ratios are underestimated by $10,300–$13,700 per quality-adjusted life year gained if quality of life losses and healthcare expenditures of competing risks are omitted in economic evaluations. Furthermore, cancer screening programs that were considered cost saving, were found not to be so following the inclusion of medical expenditures of competing risks.
Practical difficulties in quantifying quality of life losses and healthcare expenditures owing to competing risks in life years gained can be overcome. Their inclusion can have a substantial impact on the cost-effectiveness of cancer screening programs.
Meta-analysis of dye-based chromoendoscopy compared with standard- and high-definition white-light endoscopy in patients with inflammatory bowel disease at increased risk of colon cancer
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Patients with ulcerative colitis have an increased risk of colorectal cancer. We sought to assess the comparative efficacy of standard white-light endoscopy (SDWLE) or high-definition white-light endoscopy (HDWLE) versus dye-based chromoendoscopy through a meta-analysis and rate the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system.
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Of the 27,904 studies identified, 10 studies were included 6 of which were RCTs (3 SDWLE and 3 HDWLE). Seventeen percent (84/494) of patients were noted to have dysplasia using chromoendoscopy compared with 11% (55/496) with white-light endoscopy (relative risk [RR] 1.50; 95% confidence interval [CI], 1.08-2.10). When analyzed separately, chromoendoscopy (n = 249) was more effective at identifying dysplasia than SDWLE (n = 248) (RR, 2.12; 95% CI, 1.15-3.91), but chromoendoscopy (n = 245) was not more effective compared with HDWLE (n = 248) (RR, 1.36; 95% CI, 0.84-2.18). The quality of evidence was moderate. In non-RCTs, dysplasia was identified in 16% (114/698) of patients with chromoendoscopy compared with 6% (62/1069) with white-light endoscopy (RR, 3.41; 95% CI, 2.13-5.47). Chromoendoscopy (n = 58) was more effective than SDWLE (n = 141) for identification of dysplasia (RR, 3.52; 95% CI, 1.38-8.99), and chromoendoscopy (n = 113) was also more effective than HDWLE (n = 257) (RR, 3.15; 95% CI, 1.62-6.13). The quality of the evidence was very low.
Based on this meta-analysis, non-RCTs demonstrate a benefit of chromoendoscopy over SDWLE and HDWLE, whereas RCTs only show a small benefit of chromoendoscopy over SDWLE, but not over HDWLE.
Clear liquid diet before bowel preparation predicts successful chromoendoscopy in patients with inflammatory bowel disease
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First, this technique generates an increased diagnostic yield for dysplasia compared with standard white-light endoscopy, both de novo and in patients with a history or previously identified premalignant lesions.9-11 Second, the use of CE is a more cost-effective method of surveillance.12 The process of CE involves spraying a dye through an endoscopic channel or jet, either indigo carmine (non-vital stain) or methylene blue (vital stain), to delineate subtle changes in mucosal topography that may indicate the presence of nonpolypoid dysplasia.13,14
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Following a clear liquid diet the entire day before the procedure was highly predictive of the ability to perform CE. However, established risk factors for inadequate bowel preparation did not inhibit the ability to perform CE in our population. Endoscopists performing CE should consider recommending that patients follow a clear liquid diet the entire day before their examination.
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2019, Clinical Gastrointestinal Endoscopy
Patients with long-standing inflammatory bowel disease (IBD) are at an increased risk for development of colorectal cancer (CRC). Of all the risk factors associated with the development of CRC in IBD, colitis-related dysplasia appears to confer the greatest risk. The goal of endoscopic surveillance is to reduce mortality and morbidity of CRC by either detecting and resecting dysplasia or detecting CRC at an earlier and potentially curable stage. Surveillance strategies have relied on examination of the mucosa with targeted biopsies of visible lesions and random biopsy sampling. Advances in optical technology allowing for greater endoscopic identification of dysplasia and consensus that most dysplasia in patients with IBD is visible have led to a paradigm shift in our approach to surveillance and management of dysplasia. New imaging techniques such as chromoendoscopy (CE), narrow band imaging (NBI), and confocal endomicroscopy have been developed and recent evidence suggests that CE or high-definition white light endoscopy (HD WLE) are superior for dysplasia detection as a surveillance technique where appropriate expertise is available. Adoption of CE as the gold standard of surveillance has been met with by skepticism from conflicting data, operational barriers, and the need to understand the true impact of increasingly higher dysplasia detection on overall CRC mortality. This chapter will review the evolution in our understanding of dysplasia, outline the most recent surveillance guidelines, and discuss the management of dysplasia and controversies therein.
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However, in our analysis there was only one study [15] and additional studies are required to assess the role of CE in US without PSC. An economic analysis concluded that CE with target biopsies was more cost-effective than WLE with random biopsies [36]. Despite the suggested benefit in detection of dysplasia using CE in comparison to WLE, CE has some important limitations.
Endoscopic examinations are a vital diagnostic tool for dysplasia. Establishing the precision of different modes of examination is essential due to the disparate pick-up rates of dysplasia.
The aim of this article was to establish the pick-up rates of dysplastic or cancerous lesions using white light endoscopy (WLE) and random/targeted biopsies, or chromoendoscopy (CE), in patients with ulcerative colitis (UC) without primary sclerosing (PSC) or Crohn's disease (CD).
A systematic review to identify all studies up to November 2017, without language restriction, was conducted from PubMed, the Cochrane Controlled Trials Register (1960–2017), MEDLINE, CINAHL and EMBASE (1981–2017). MeSH and text word terms used included “ulcerative colitis”, “dysplasia”, “random biopsy”, “targeted biopsy”, “colonoscopy”, “white light”, and “chromoendoscopy”. Further searches were performed using the bibliographies of these articles.
All studies reporting on colonoscopy detection rates of dysplasia and cancers in UC without involvement of PSC or CD were included. There was no age restriction to include patients.
Outcome data were extracted by 2 authors independently using outcome measures defined a priori. Quality assessment was performed using the Newcastle-Ottawa scales.
Data were extracted and analysed according to meta-analytical techniques using comprehensive meta-analysis. The pooled overall pick-up rate of dysplastic/cancerous lesions on WLE random biopsies was 5.6% [Event rate 0.06 (0.01, 0.23), df = 4, I2 = 94%]. Using a combined random and targeted approach with WLE the incidence was 5.1% [Event rate 0.05 (0.03, 0.09), df = 4, I2 = 96%]. One study reported on CE and found a 7% pick-up rate for dysplastic lesions.
Endoscopic examination of UC patients without PSC identifies dysplastic or cancerous lesions in 5–7% of cases. WLE and random biopsies may pick-up a similar number of lesions to targeted biopsies, however the number of biopsies may need to be greater to achieve this equivalence. CE has a slightly higher pick-up rate. Further comparative studies are required to strengthen the body of evidence.

View all citing articles on Scopus

: DISCLOSURE: Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Awards T32DK007191, K23 DK091742, K24 DK098311, and P30 DK043351. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. A. Ananthakrishnan served on scientific advisory boards for Prometheus, Inc, Janssen pharmaceuticals, and Cubist pharmaceuticals. A. Chan served as a consultant for Bayer HealthCare, Pfizer Inc, and Millennium Pharmaceuticals. All other authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr Chan at [email protected].

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Original articleClinical endoscopyCost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Model design

Base-case analyses

Discussion

Gastroenterology

Gastrointest Endosc

Gastroenterology

Clin Gastroenterol Hepatol

Gastroenterology

Gastrointest Endosc

Gastroenterology

Dig Liver Dis

Clin Gastroenterol Hepatol

J Am Coll Surg

Gastrointest Endosc

Am J Gastroenterol

Am J Gastroenterol

Clin Gastroenterol Hepatol

Gastrointest Endosc

Dig Liver Dis

Gastroenterology

Gastroenterology

Gastrointest Endosc

Decreasing risk of colorectal cancer in patients with inflammatory bowel disease over 30 years

Gastroenterology

Should chromoendoscopy be the standard of care in ulcerative colitis dysplasia surveillance?

Gastroenterol Hepatol (NY)

Cost effectiveness of ulcerative colitis surveillance in the setting of 5-aminosalicylates

Am J Gastroenterol

The risk of colorectal cancer in ulcerative colitis: a meta-analysis

Gut

Original article
Clinical endoscopy
Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis