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Shahidi N, Cheung WY. Colorectal cancer screening: Opportunities to improve uptake, outcomes, and disparities. World J Gastrointest Endosc 2016; 8:733-740. [PMID: 28042387 PMCID: PMC5159671 DOI: 10.4253/wjge.v8.i20.733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/05/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer screening has become a standard of care in industrialized nations for those 50 to 75 years of age, along with selected high-risk populations. While colorectal cancer screening has been shown to reduce both the incidence and mortality of colorectal cancer, it is a complex multi-disciplinary process with a number of important steps that require optimization before tangible improvements in outcomes are possible. For both opportunistic and programmatic colorectal cancer screening, poor participant uptake remains an ongoing concern. Furthermore, current screening modalities (such as the guaiac based fecal occult blood test, fecal immunochemical test and colonoscopy) may be used or performed suboptimally, which can lead to missed neoplastic lesions and unnecessary endoscopic evaluations. The latter poses the risk of adverse events, such as perforation and post-polypectomy bleeding, as well as financial impacts to the healthcare system. Moreover, ongoing disparities in colorectal cancer screening persist among marginalized populations, including specific ethnic minorities (African Americans, Hispanics, Asians, Indigenous groups), immigrants, and those who are economically disenfranchised. Given this context, we aimed to review the current literature on these important areas pertaining to colorectal cancer screening, particularly focusing on the guaiac based fecal occult blood test, the fecal immunochemical test and colonoscopy.
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Altobelli E, Angeletti PM, Latella G. Role of Urinary Biomarkers in the Diagnosis of Adenoma and Colorectal Cancer: A Systematic Review and Meta-Analysis. J Cancer 2016; 7:1984-2004. [PMID: 27877214 PMCID: PMC5118662 DOI: 10.7150/jca.16244] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/16/2016] [Indexed: 12/23/2022] Open
Abstract
The growing interest in enhancing and spreading colorectal cancer (CRC) screening has been stimulating the exploration of novel biomarkers with greater sensitivity and specificity than immunochemical faecal occult blood test (iFOBT). The present study provides i) a systematic review of the urinary biomarkers that have been tested to achieve early CRC diagnosis and assess the risk of colorectal adenoma and adenocarcinoma, and ii) a meta-analysis of the data regarding the urinary prostaglandin (PG) metabolite PGE-M. As regard to gene markers, we found significantly different percent methylation of the vimentin gene in CRC patients and healthy controls (HC) (p<0.0001). Respect to metabolism of nitrogenous bases, cytidine, 1-methyladenosine, and adenosine, have higher concentrations in CRC patients than in HC (respectively, p<0.01, p=0.01, and p<0.01). As regard to spermine we found that N1,N12 diacetyl spermine (DiAcSpm) and N1, N8 diacetylspermidine (DiAcSpd) were significantly higher in CRC than in HC (respectively p=0.01 and p<0.01). Respect to PGE-M, levels were higher in CRC than in those with multiple polyposis (p<0.006) and HC subjects (p<0.0004). PGE-M seems to be the most interesting and promising urinary marker for CRC and adenoma risk assessment and for CRC screening. In conclusion, evidence suggests that urinary biomarker could have a potential role as urinary biomarkers in the diagnosis of colorectal cancer. Particularly, PGE-M seems to be the most promising urinary marker for CRC early detection.
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Affiliation(s)
- Emma Altobelli
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
- Epidemiology and Biostatistics Unit, AUSL Teramo, University of L'Aquila, L'Aquila, Italy
| | - Paolo Matteo Angeletti
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Latella
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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Imperiale TF, Yu M, Monahan PO, Stump TE, Tabbey R, Glowinski E, Ransohoff DF. Risk of Advanced Neoplasia Using the National Cancer Institute's Colorectal Cancer Risk Assessment Tool. J Natl Cancer Inst 2016; 109:2905646. [PMID: 27582444 DOI: 10.1093/jnci/djw181] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 06/20/2016] [Indexed: 12/13/2022] Open
Abstract
Background There is no validated, discriminating, and easy-to-apply tool for estimating risk of colorectal neoplasia. We studied whether the National Cancer Institute's (NCI's) Colorectal Cancer (CRC) Risk Assessment Tool, which estimates future CRC risk, could estimate current risk for advanced colorectal neoplasia among average-risk persons. Methods This cross-sectional study involved individuals age 50 to 80 years undergoing first-time screening colonoscopy. We measured medical and family history, lifestyle information, and physical measures and calculated each person's future CRC risk using the NCI tool's logistic regression equation. We related quintiles of future CRC risk to the current risk of advanced neoplasia (sessile serrated polyp or tubular adenoma ≥ 1 cm, a polyp with villous histology or high-grade dysplasia, or CRC). All statistical tests were two-sided. Results For 4457 (98.5%) with complete data (mean age = 57.2 years, SD = 6.6 years, 51.7% women), advanced neoplasia prevalence was 8.26%. Based on quintiles of five-year estimated absolute CRC risk, current risks of advanced neoplasia were 2.1% (95% confidence interval [CI] = 1.3% to 3.3%), 4.8% (95% CI = 3.5% to 6.4%), 6.4% (95% CI = 4.9% to 8.2%), 10.0% (95% CI = 8.1% to 12.1%), and 17.6% (95% CI = 15.5% to 20.6%; P < .001). For quintiles of estimated 10-year CRC risk, corresponding current risks for advanced neoplasia were 2.2% (95% CI = 1.4% to 3.5%), 4.8% (95% CI = 3.5% to 6.4%), 6.5% (95% CI = 5.0% to 8.3%), 9.3% (95% CI = 7.5% to 11.4%), and 18.4% (95% CI = 15.9% to 21.1%; P < .001). Among persons with an estimated five-year CRC risk above the median, current risk for advanced neoplasia was 12.8%, compared with 3.7% among those below the median (relative risk = 3.4, 95 CI = 2.7 to 4.4). Conclusions The NCI's Risk Assessment Tool, which estimates future CRC risk, may be used to estimate current risk for advanced neoplasia, making it potentially useful for tailoring and improving CRC screening efficiency among average-risk persons.
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Affiliation(s)
- Thomas F Imperiale
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine; Regenstrief Institute, Inc. and Center for Innovation, Health Services Research and Development, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Menggang Yu
- Division of Gastroenterology and Hepatology, Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Patrick O Monahan
- Division of Gastroenterology and Hepatology, Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Timothy E Stump
- Division of Gastroenterology and Hepatology, Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Rebeka Tabbey
- Division of Gastroenterology and Hepatology, Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | | | - David F Ransohoff
- Department of Medicine University of North Carolina, Chapel Hill, NC
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Scherr AL, Gdynia G, Salou M, Radhakrishnan P, Duglova K, Heller A, Keim S, Kautz N, Jassowicz A, Elssner C, He YW, Jaeger D, Heikenwalder M, Schneider M, Weber A, Roth W, Schulze-Bergkamen H, Koehler BC. Bcl-xL is an oncogenic driver in colorectal cancer. Cell Death Dis 2016; 7:e2342. [PMID: 27537525 PMCID: PMC5108319 DOI: 10.1038/cddis.2016.233] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/22/2016] [Accepted: 07/01/2016] [Indexed: 02/07/2023]
Abstract
Colorectal cancer (CRC) is the second most common malignant neoplasia in women and men worldwide. The B-cell lymphoma 2 (Bcl-2) protein family is mainly known for its pivotal role in the regulation of the mitochondrial death pathway. Anti-apoptotic Bcl-2 proteins may provide survival benefits and induce therapy resistance in cancer cells. Among anti-apoptotic Bcl-2 proteins, we found solely Bcl-xL strongly upregulated in human CRC specimens. In order to study protein function in the context of tumor initiation and progression in vivo, we generated a mouse model lacking Bcl-xL in intestinal epithelial cells (Bcl-xLIEC-KO). If challenged in an inflammation-driven tumor model, Bcl-xLIEC-KO mice showed a significantly reduced tumor burden with lower tumor numbers per animal and decreased tumor sizes. Analysis of cell death events by immunohistochemistry and immunoblotting revealed a striking increase of apoptosis in Bcl-xL-negative tumors. qRT-PCR and immunohistochemistry excluded changes in proliferative capacity and immune cell infiltration as reasons for the reduced tumor load and thereby identify apoptosis as key mechanism. Human CRC tissue was cultured ex vivo and treated with the small molecule compound ABT-737, which inhibits Bcl-xL and Bcl-2. Under ABT-737 treatment, the amount of apoptotic tumor cells significantly increased compared with controls, whereas proliferation levels remained unaltered. In summary, our findings identify Bcl-xL as a driver in colorectal tumorigenesis and cancer progression, making it a valuable target for clinical application.
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Affiliation(s)
- Anna-Lena Scherr
- National Center for Tumor Diseases, Department of Medical Oncology and Heidelberg University Hospital, Internal Medicine VI, 69120 Heidelberg, Germany
| | - Georg Gdynia
- Clinical Cooperation Unit (CCU) Molecular Tumor Pathology, German Cancer Research Center (DKFZ), Heidelberg 69120, Germany.,Institute of Pathology, Department of Surgical Pathology, University Hospital Heidelberg, Heidelberg 69120, Germany
| | - Mariam Salou
- Division of Translational Oncology, National Center for Tumor Diseases and German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Praveen Radhakrishnan
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg 69120, Germany
| | - Katarina Duglova
- Institute of Pathology, Department of Surgical Pathology, University Hospital Heidelberg, Heidelberg 69120, Germany
| | - Anette Heller
- Institute of Pathology, Department of Surgical Pathology, University Hospital Heidelberg, Heidelberg 69120, Germany
| | - Sophia Keim
- National Center for Tumor Diseases, Department of Medical Oncology and Heidelberg University Hospital, Internal Medicine VI, 69120 Heidelberg, Germany
| | - Nicole Kautz
- National Center for Tumor Diseases, Department of Medical Oncology and Heidelberg University Hospital, Internal Medicine VI, 69120 Heidelberg, Germany
| | - Adam Jassowicz
- National Center for Tumor Diseases, Department of Medical Oncology and Heidelberg University Hospital, Internal Medicine VI, 69120 Heidelberg, Germany
| | - Christin Elssner
- National Center for Tumor Diseases, Department of Medical Oncology and Heidelberg University Hospital, Internal Medicine VI, 69120 Heidelberg, Germany
| | - You-Wen He
- Department of Immunology, Duke University Medical Center, Durham, NC 27710, USA
| | - Dirk Jaeger
- National Center for Tumor Diseases, Department of Medical Oncology and Heidelberg University Hospital, Internal Medicine VI, 69120 Heidelberg, Germany
| | - Mathias Heikenwalder
- Institute of Virology, Technische Universität München and Helmholtz Zentrum München, Munich 81675, Germany.,Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg 69120, Germany
| | - Achim Weber
- Institute of Surgical Pathology, University and University Hospital Zurich, Zurich 8091, Switzerland
| | - Wilfried Roth
- Institute of Pathology, University Medical Center Mainz, Mainz 55131, Germany
| | | | - Bruno Christian Koehler
- National Center for Tumor Diseases, Department of Medical Oncology and Heidelberg University Hospital, Internal Medicine VI, 69120 Heidelberg, Germany
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Abstract
Most colon tumors develop via a multistep process involving a series of histological, morphological, and genetic changes that accumulate over time. This has allowed for screening and detection of early-stage precancerous polyps before they become cancerous in individuals at average risk for colorectal cancer (CRC), which may lead to substantial decreases in the incidence of CRC. Despite the known benefits of early screening, CRC remains the second leading cause of cancer-related deaths in the United States. Hence, it is important for health care providers to have an understanding of the risk factors for CRC and various stages of disease development in order to recommend appropriate screening strategies. This article provides an overview of the histological/molecular changes that characterize the development of CRC. It describes the available CRC screening methods and their advantages and limitations and highlights the stages of CRC development in which each screening method is most effective.
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Affiliation(s)
- Karen Simon
- Ventura County Gastroenterology Medical Group, Inc., Camarillo, CA, USA
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56
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Abstract
Colorectal cancer (CRC) forms an important public health problem, especially in developed countries. CRC screening tests can be used to identify asymptomatic individuals with CRC precursors and (early) cancer. Removal of these lesions reduces CRC incidence and prevents CRC-related mortality. There are a range of screening tests available, each with advantages and disadvantages. Stool screening tests can broadly be divided into fecal occult blood tests (FOBTs) and molecular biomarker test, such as DNA/RNA marker tests, protein markers, and fecal microbiome marker tests. Guaiac fecal occult blood tests (gFOBT) have been demonstrated in large randomized screening trials to reduce CRC mortality. Fecal immunochemical tests (FIT) have superior adherence, usability, and accuracy as compared to gFOBT. Advantage of the use of quantitative FITs in CRC screening programs is the cut-off level that can be adjusted. Molecular biomarker DNA tests have shown to detect significantly more cancers than FIT. By combining biomarker DNA tests with FIT, sensitivity for advanced adenomas can be increased significantly. However, it has lower specificity thus demands more colonoscopy resources, is more cumbersome, and costly. The adherence has not been assessed in population screening trials. For these reasons, FIT is therefore at present regarded as the preferred method of non-invasive CRC screening. This chapter will review the current status of fecal test-based CRC screening.
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Nadeem H, Jayakrishnan TT, Rajeev R, Johnston FM, Gamblin TC, Turaga KK. Cost Differential of Chemotherapy for Solid Tumors. J Oncol Pract 2016; 12:e299-307, 251. [PMID: 26860586 DOI: 10.1200/jop.2015.006700] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A significant portion of national cancer expenditure is attributed to chemotherapy.Although the National Comprehensive Cancer Network has generated recommendations for the treatment of various solid tumors, the outlined chemotherapeutic strategies lack information about the cost differential for increasing effectiveness. METHODS Chemotherapy regimens (curative [adjuvant/neoadjuvant] and metastatic therapy) and dosages outlined in the 2013 National Comprehensive Cancer Network guidelines were acquired for four common cancers: bladder, breast, colon, and lung. Baseline drug and treatment costs (in US dollars)were calculated for the average US adult male on the basis of the payment allowance in the 2013 Medicare Part B average sales price (ASP) drug pricing files. Costs were extrapolated for a treatment period of 6 months. RESULTS Of the 62 regimens included, the 6-month mean cost of chemotherapy was $26,989 ± $29,971, and the median cost was $9,611 (interquartile range, $6,305-$39,383). The mean cost of metastatic cancer therapy regimens (n = 32) was $35,315 ± 32,962 compared with $18,107 ± 23,873 for curative therapy (P = .02). Of the 13 regimens with biologics used, the mean costs were $77,278 versus $13,646 for 49 regimens that did not use biologics (P<.001). The cost differential between extremes of costs for regimens with presumed similar efficacy was $90,843 ($79,165 for curative therapy and $90,210 for metastatic cancer therapy). The highest cost differential was noted in breast cancer regimens at $71,041 for metastatic cancer therapy and $63,926 for curative therapy. CONCLUSION A significant cost differential exists between chemotherapeutic regimens for the most common solid tumors. Incorporation of costs and incremental effectiveness in current guidelines may encourage socially responsible practice patterns.
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Liss DT, French DD, Buchanan DR, Brown T, Magner BG, Kollar S, Baker DW. Outreach for Annual Colorectal Cancer Screening: A Budget Impact Analysis for Community Health Centers. Am J Prev Med 2016; 50:e54-61. [PMID: 26362405 DOI: 10.1016/j.amepre.2015.07.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 06/21/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Fecal immunochemical testing (FIT) is an attractive approach for colorectal cancer screening at community health centers. This budget impact analysis investigated benefits and costs of FIT outreach-with FIT kits mailed to patients, followed by reminders and phone calls-compared with point-of-care (POC) strategies. METHODS Five screening and cost outcomes were simulated over 1 year at a "base case" community health center serving 1000 screening-eligible patients: (1) FIT completion among patients due for screening; (2) proportion up-to-date on screening; (3) cost per patient due for screening; (4) cost per completed FIT; and (5) total organizational cost. Uncertainty analysis investigated potential savings from optimizing staff workflows during FIT outreach. Data were collected in 2012-2014, with analysis conducted 2014-2015. RESULTS Using POC strategies, 24.0% of patients due for screening completed FIT, versus 42.4% under outreach (18.4% absolute difference). When calculations included patients up-to-date on screening from prior colonoscopy, 41.7% were up-to-date via POC, versus 55.8% for outreach (14.1% absolute difference). POC cost $4.93 per patient, versus $30.43 for outreach ($25.50 difference). Cost per patient screened was $20.60 for POC and $71.84 for outreach ($51.24 difference). Total organizational cost was $3,779 for POC distribution and $23,315 for outreach ($19,536 difference). Outreach costs decreased by approximately one fourth under optimized workflows. CONCLUSIONS Outreach is an effective, practical, relatively low-cost strategy; costs could be reduced further by optimizing staff workflows. Despite its value, outreach costs more than POC distribution and may be difficult for community health centers to implement under current payment models.
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Affiliation(s)
- David T Liss
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Advancing Equity in Clinical Preventive Services, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Dustin D French
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Veterans Affairs Health Services Research and Development Service, Chicago, Illinois
| | | | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Advancing Equity in Clinical Preventive Services, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - David W Baker
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Advancing Equity in Clinical Preventive Services, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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QI CHONG, HONG LIANG, CHENG ZHIJIAN, YIN QINGZHANG. Identification of metastasis-associated genes in colorectal cancer using metaDE and survival analysis. Oncol Lett 2016; 11:568-574. [PMID: 26870249 PMCID: PMC4726934 DOI: 10.3892/ol.2015.3956] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 05/27/2015] [Indexed: 12/24/2022] Open
Abstract
The aim of the present study was to detect the candidate genes involved in the metastasis of colorectal cancer (CRC). Gene expression profiles of primary and metastatic CRC samples in the GSE14297 and GSE49355 datasets were downloaded from the Gene Expression Omnibus database. Subsequent to processing, Fishers exact test and the metaDE package in R language were applied to screen the differentially expressed genes (DEGs) between primary and metastatic CRC samples. In addition, function and pathway enrichment analysis was performed using online tools in the Database for Annotation, Visualization, and Integrated Discovery resource and common DEGs in GSE14297 and GSE49355 were identified. Their expression values in another dataset, GSE29621, were then collected in order to screen the genes with high standard deviations between primary and metastatic samples, which were considered as candidate metastasis-associated genes. Candidate genes were finally verified by performing survival analysis via the log-rank test. A total of 370 DEGs were screened in GSE14297 and GSE49355, and 77 common DEGs were identified. Upregulated DEGs were mainly enriched in the immune, energy metabolism and drug metabolism-associated functions. Downregulated DEGs were mainly enriched in cell adhesion-associated functions. A total of 12 genes, including the carbonic anhydrase II (CA2), carcinoembryonic antigen-related cell adhesion molecule 7 (CEACAM7), Fc fragment of immunoglobulin G binding protein (FCGBP), and placenta-specific 8 (PLAC8), were the candidate metastasis-associated genes, among which FCGBP expression significantly decreased the overall survival time of patients. The selected candidate metastasis-associated gene, FCGBP, may be used as a potential therapeutic target in patients with metastatic CRC.
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Affiliation(s)
- CHONG QI
- Department of General Surgery, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai 200240, P.R. China
| | - LIANG HONG
- Department of General Surgery, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai 200240, P.R. China
| | - ZHIJIAN CHENG
- Department of General Surgery, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai 200240, P.R. China
| | - QINGZHANG YIN
- Department of General Surgery, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai 200240, P.R. China
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Berger BM, Schroy PC, Dinh TA. Screening for Colorectal Cancer Using a Multitarget Stool DNA Test: Modeling the Effect of the Intertest Interval on Clinical Effectiveness. Clin Colorectal Cancer 2015; 15:e65-74. [PMID: 26792032 DOI: 10.1016/j.clcc.2015.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/01/2015] [Accepted: 12/09/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND A multitarget stool DNA (mt-sDNA) test was recently approved for colorectal cancer (CRC) screening for men and women, aged ≥ 50 years, at average risk of CRC. The guidelines currently recommend a 3-year interval for mt-sDNA testing in the absence of empirical data. We used clinical effectiveness modeling to project decreases in CRC incidence and related mortality associated with mt-sDNA screening to help inform interval setting. MATERIALS AND METHODS The Archimedes model (Archimedes Inc., San Francisco, CA) was used to conduct a 5-arm, virtual, clinical screening study of a population of 200,000 virtual individuals to compare the clinical effectiveness of mt-sDNA screening at 1-, 3-, and 5-year intervals compared with colonoscopy at 10-year intervals and no screening for a 30-year period. The study endpoints were the decrease in CRC incidence and related mortality of each strategy versus no screening. Cost-effectiveness ratios (US dollars per quality-adjusted life year [QALY]) of mt-sDNA intervals were calculated versus no screening. RESULTS Compared with 10-year colonoscopy, annual mt-sDNA testing produced similar reductions in CRC incidence (65% vs. 63%) and related mortality (73% vs. 72%). mt-sDNA testing at 3-year intervals reduced the CRC incidence by 57% and CRC mortality by 67%, and mt-sDNA testing at 5-year intervals reduced the CRC incidence by 52% and CRC mortality by 62%. At an average price of $600 per test, the annual, 3-year, and 5-year mt-sDNA screening costs would be $20,178, $11,313, and $7388 per QALY, respectively, compared with no screening. CONCLUSION These data suggest that screening every 3 years using a multitarget mt-sDNA test provides reasonable performance at acceptable cost.
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Affiliation(s)
| | - Paul C Schroy
- Department of Gastroenterology, Boston University School of Medicine, Boston, MA
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Kuipers EJ, Grady WM, Lieberman D, Seufferlein T, Sung JJ, Boelens PG, van de Velde CJH, Watanabe T. Colorectal cancer. Nat Rev Dis Primers 2015; 1:15065. [PMID: 27189416 PMCID: PMC4874655 DOI: 10.1038/nrdp.2015.65] [Citation(s) in RCA: 971] [Impact Index Per Article: 107.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Colorectal cancer had a low incidence several decades ago. However, it has become a predominant cancer and now accounts for approximately 10% of cancer-related mortality in western countries. The 'rise' of colorectal cancer in developed countries can be attributed to the increasingly ageing population, unfavourable modern dietary habits and an increase in risk factors, such as smoking, low physical exercise and obesity. New treatments for primary and metastatic colorectal cancer have emerged, providing additional options for patients; these treatments include laparoscopic surgery for primary disease, more-aggressive resection of metastatic disease (such as liver and pulmonary metastases), radiotherapy for rectal cancer, and neoadjuvant and palliative chemotherapies. However, these new treatment options have had limited impact on cure rates and long-term survival. For these reasons, and the recognition that colorectal cancer is long preceded by a polypoid precursor, screening programmes have gained momentum. This Primer provides an overview of the current state of the art of knowledge on the epidemiology and mechanisms of colorectal cancer, as well as on diagnosis and treatment.
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Affiliation(s)
- Ernst J. Kuipers
- Erasmus MC University Medical Center, s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - William M. Grady
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, OR, USA
| | | | - Joseph J. Sung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Petra G. Boelens
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Toshiaki Watanabe
- Department of Surgical Oncology and Vascular Surgery, University of Tokyo, and the University of Tokyo Hospital, Tokyo, Japan
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Robertson DJ, Imperiale TF. Stool Testing for Colorectal Cancer Screening. Gastroenterology 2015; 149:1286-93. [PMID: 26033632 DOI: 10.1053/j.gastro.2015.05.045] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/11/2015] [Accepted: 05/26/2015] [Indexed: 12/14/2022]
Abstract
Colorectal cancer (CRC) screening has been shown to reduce CRC incidence and mortality and is widely recommended. However, despite the demonstrated benefits of screening and ongoing efforts to improve screening rates, a large percentage of the population remains unscreened. Noninvasive stool based tests offer great opportunity to enhance screening uptake. The evidence supporting the use of both fecal immunochemical testing (FIT) and stool DNA (sDNA) has been growing rapidly and both tests are now commercially available for use. Other stool biomarkers (eg, RNA and protein based) are also actively under study both for use independently and as adjuncts to the currently available tests. This mini review provides current, state of the art knowledge about noninvasive stool based screening. It includes a more detailed examination of those tests currently in use (ie, FIT and sDNA) but also provides an overview of stool testing options under development (ie, protein and RNA).
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Affiliation(s)
- Douglas J Robertson
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Dartmouth Medical School and Dartmouth Institute, Hanover, New Hampshire.
| | - Thomas F Imperiale
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; and Regenstrief Institute, Inc, Center of Innovation, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
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Schreuders EH, Ruco A, Rabeneck L, Schoen RE, Sung JJY, Young GP, Kuipers EJ. Colorectal cancer screening: a global overview of existing programmes. Gut 2015; 64:1637-49. [PMID: 26041752 DOI: 10.1136/gutjnl-2014-309086] [Citation(s) in RCA: 815] [Impact Index Per Article: 90.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/13/2015] [Indexed: 02/06/2023]
Abstract
Colorectal cancer (CRC) ranks third among the most commonly diagnosed cancers worldwide, with wide geographical variation in incidence and mortality across the world. Despite proof that screening can decrease CRC incidence and mortality, CRC screening is only offered to a small proportion of the target population worldwide. Throughout the world there are widespread differences in CRC screening implementation status and strategy. Differences can be attributed to geographical variation in CRC incidence, economic resources, healthcare structure and infrastructure to support screening such as the ability to identify the target population at risk and cancer registry availability. This review highlights issues to consider when implementing a CRC screening programme and gives a worldwide overview of CRC burden and the current status of screening programmes, with focus on international differences.
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Affiliation(s)
- Eline H Schreuders
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Arlinda Ruco
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Linda Rabeneck
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada Department of Medicine, University of Toronto, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Robert E Schoen
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph J Y Sung
- Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Graeme P Young
- Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, South Australia, Australia
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
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Steffen LE, Boucher KM, Damron BH, Pappas LM, Walters ST, Flores KG, Boonyasiriwat W, Vernon SW, Stroup AM, Schwartz MD, Edwards SL, Kohlmann WK, Lowery JT, Wiggins CL, Hill DA, Higginbotham JC, Burt R, Simmons RG, Kinney AY. Efficacy of a Telehealth Intervention on Colonoscopy Uptake When Cost Is a Barrier: The Family CARE Cluster Randomized Controlled Trial. Cancer Epidemiol Biomarkers Prev 2015; 24:1311-8. [PMID: 26101306 PMCID: PMC4734378 DOI: 10.1158/1055-9965.epi-15-0150] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/02/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We tested the efficacy of a remote tailored intervention Tele-Cancer Risk Assessment and Evaluation (TeleCARE) compared with a mailed educational brochure for improving colonoscopy uptake among at-risk relatives of colorectal cancer patients and examined subgroup differences based on participant reported cost barriers. METHODS Family members of colorectal cancer patients who were not up-to-date with colonoscopy were randomly assigned as family units to TeleCARE (N = 232) or an educational brochure (N = 249). At the 9-month follow-up, a cost resource letter listing resources for free or reduced-cost colonoscopy was mailed to participants who had reported cost barriers and remained nonadherent. Rates of medically verified colonoscopy at the 15-month follow-up were compared on the basis of group assignment and within group stratification by cost barriers. RESULTS In intent-to-treat analysis, 42.7% of participants in TeleCARE and 24.1% of participants in the educational brochure group had a medically verified colonoscopy [OR, 2.37; 95% confidence interval (CI) 1.59-3.52]. Cost was identified as a barrier in both groups (TeleCARE = 62.5%; educational brochure = 57.0%). When cost was not a barrier, the TeleCARE group was almost four times as likely as the comparison to have a colonoscopy (OR, 3.66; 95% CI, 1.85-7.24). The intervention was efficacious among those who reported cost barriers; the TeleCARE group was nearly twice as likely to have a colonoscopy (OR, 1.99; 95% CI, 1.12-3.52). CONCLUSIONS TeleCARE increased colonoscopy regardless of cost barriers. IMPACT Remote interventions may bolster screening colonoscopy regardless of cost barriers and be more efficacious when cost barriers are absent.
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Affiliation(s)
- Laurie E Steffen
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Kenneth M Boucher
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah. Department of Oncologic Sciences, University of Utah, Salt Lake City, Utah
| | | | - Lisa M Pappas
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Scott T Walters
- Department of School of Public Health Behavioral and Community Health, University of North Texas Health Science Center, Fort Worth, Texas
| | - Kristina G Flores
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Sally W Vernon
- Division of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health, Houston, Texas
| | - Antoinette M Stroup
- Department of Epidemiology, Rutgers School of Public Health, Piscataway Township, New Jersey. Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Marc D Schwartz
- Department of Oncology, Georgetown University, Washington, DC. Lombardi Comprehensive Cancer Center, Washington, DC
| | - Sandra L Edwards
- Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Wendy K Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jan T Lowery
- Department of Epidemiology, University of Colorado School of Public Health, Aurora, Colorado
| | - Charles L Wiggins
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Deirdre A Hill
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - John C Higginbotham
- Community and Rural Medicine Institute for Rural Health Research, College of Community Health Sciences, University of Alabama, Tuscaloosa, Alabama
| | - Randall Burt
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Anita Y Kinney
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.
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65
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Moreno CC, Mittal PK, Sullivan PS, Rutherford R, Staley CA, Cardona K, Hawk NN, Dixon WT, Kitajima HD, Kang J, Small WC, Oshinski J, Votaw JR. Colorectal Cancer Initial Diagnosis: Screening Colonoscopy, Diagnostic Colonoscopy, or Emergent Surgery, and Tumor Stage and Size at Initial Presentation. Clin Colorectal Cancer 2015; 15:67-73. [PMID: 26602596 DOI: 10.1016/j.clcc.2015.07.004] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/20/2015] [Indexed: 01/05/2023]
Abstract
INTRODUCTION/BACKGROUND Rates of colorectal cancer screening are improving but remain suboptimal. Limited information is available regarding how patients are diagnosed with colorectal cancer (for example, asymptomatic screened patients or diagnostic workup because of the presence of symptoms). The purpose of this investigation was to determine how patients were diagnosed with colorectal cancer (screening colonoscopy, diagnostic colonoscopy, or emergent surgery) and tumor stage and size at diagnosis. PATIENTS AND METHODS Adults evaluated between 2011 and 2014 with a diagnosis of colorectal cancer were identified. Clinical notes, endoscopy reports, surgical reports, radiology reports, and pathology reports were reviewed. Sex, race, ethnicity, age at the time of initial diagnosis, method of diagnosis, presenting symptom(s), and primary tumor size and stage at diagnosis were recorded. Colorectal cancer screening history was also recorded. RESULTS The study population was 54% male (265 of 492) with a mean age of 58.9 years (range, 25-93 years). Initial tissue diagnosis was established at the time of screening colonoscopy in 10.7%, diagnostic colonoscopy in 79.2%, and during emergent surgery in 7.1%. Cancers diagnosed at the time of screening colonoscopy were more likely to be stage 1 than cancers diagnosed at the time of diagnostic colonoscopy or emergent surgery (38.5%, 7.2%, and 0%, respectively). Median tumor size was 3.0 cm for the screening colonoscopy group, 4.6 cm for the diagnostic colonoscopy group, and 5.0 cm for the emergent surgery group. At least 31% of patients diagnosed at the time of screening colonoscopy, 19% of patients diagnosed at the time of diagnostic colonoscopy, and 26% of patients diagnosed at the time of emergent surgery had never undergone a screening colonoscopy. CONCLUSION Nearly 90% of colorectal cancer patients were diagnosed after development of symptoms and had more advanced disease than asymptomatic screening patients. Colorectal cancer outcomes will be improved by improving rates of colorectal cancer screening.
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Affiliation(s)
- Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Pardeep K Mittal
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | | | - Robin Rutherford
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Charles A Staley
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Kenneth Cardona
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Natalyn N Hawk
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
| | - W Thomas Dixon
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Hiroumi D Kitajima
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Jian Kang
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA; Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, GA
| | - William C Small
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - John Oshinski
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - John R Votaw
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
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Meester RGS, Doubeni CA, Zauber AG, Goede SL, Levin TR, Corley DA, Jemal A, Lansdorp-Vogelaar I. Public health impact of achieving 80% colorectal cancer screening rates in the United States by 2018. Cancer 2015; 121:2281-5. [PMID: 25763558 PMCID: PMC4567966 DOI: 10.1002/cncr.29336] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/09/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND The National Colorectal Cancer Roundtable, a national coalition of public, private, and voluntary organizations, has recently announced an initiative to increase colorectal cancer (CRC) screening rates in the United States to 80% by 2018. The authors evaluated the potential public health benefits of achieving this goal. METHODS The authors simulated the 1980 through 2030 United States population of individuals aged 50 to 100 years using microsimulation modeling. Test-specific historical screening rates were based on National Health Interview Survey data for 1987 through 2013. The effects of increasing screening rates from approximately 58% in 2013 to 80% in 2018 were compared to a scenario in which the screening rate remained approximately constant. The outcomes were cancer incidence and mortality rates and numbers of CRC cases and deaths during short-term follow-up (2013-2020) and extended follow-up (2013-2030). RESULTS Increasing CRC screening rates to 80% by 2018 would reduce CRC incidence rates by 17% and mortality rates by 19% during short-term follow-up and by 22% and 33%, respectively, during extended follow-up. These reductions would amount to a total of 277,000 averted new cancers and 203,000 averted CRC deaths from 2013 through 2030. CONCLUSIONS Achieving the goal of increasing the uptake of CRC screening in the United States to 80% by 2018 may have a considerable public health impact by averting approximately 280,000 new cancer cases and 200,000 cancer deaths within <20 years. Cancer 2015;121:2281–2285. © 2015 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
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Affiliation(s)
- Reinier G S Meester
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, and the Department of Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Leonard Davis Center for Health Economics and Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - S Luuk Goede
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | | | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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67
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Alberts SR, Yu TM, Behrens RJ, Renfro LA, Srivastava G, Soori GS, Dakhil SR, Mowat RB, Kuebler JP, Kim GP, Mazurczak MA, Hornberger J. Comparative economics of a 12-gene assay for predicting risk of recurrence in stage II colon cancer. PHARMACOECONOMICS 2014; 32:1231-43. [PMID: 25154747 PMCID: PMC4244576 DOI: 10.1007/s40273-014-0207-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Prior economic analysis that compared the 12-gene assay to published patterns of care predicted the assay would improve outcomes while lowering medical costs for stage II, T3, mismatch-repair-proficient (MMR-P) colon cancer patients. This study assessed the validity of those findings with real-world adjuvant chemotherapy (aCT) recommendations from the US third-party payer perspective. METHODS Costs and quality-adjusted life-years (QALYs) were estimated for stage II, T3, MMR-P colon cancer patients using guideline-compliant, state-transition probability estimation methods in a Markov model. A study of 141 patients from 17 sites in the Mayo Clinic Cancer Research Consortium provided aCT recommendations before and after knowledge of the 12-gene assay results. Progression and adverse events data with aCT regimens were based on published literature. Drug and administration costs for aCT were obtained from 2014 Medicare Fee Schedule. Sensitivity analyses evaluated the drivers and robustness of the primary outcomes. RESULTS After receiving the 12-gene assay results, physician recommendations in favor of aCT decreased 22 %; fluoropyrimidine monotherapy and FOLFOX recommendations each declined 11 %. Average per-patient drugs, administration, and adverse events costs decreased $US2,339, $US733, and $US3,211, respectively. Average total direct medical costs decreased $US991. Average patient well-being improved by 0.114 QALYs. Savings are expected to persist even if the cost of oxaliplatin drops by >75 % due to generic substitution. CONCLUSIONS This study provides evidence that real-world changes in aCT recommendations due to the 12-gene assay are likely to reduce direct medical costs and improve well-being for stage II, T3, MMR-P colon cancer patients.
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Affiliation(s)
| | - Tiffany M. Yu
- Cedar Associates LLC, 3715 Haven Avenue, Suite 100, Menlo Park, CA 94025 USA
| | - Robert J. Behrens
- Medical Oncology and Hematology Associates, 1221 Pleasant St, Des Moines, IA 50309 USA
| | | | | | - Gamini S. Soori
- Alegant Bergan Mercy Cancer Center, 7500 Mercy Rd, Omaha, NE 68124 USA
| | - Shaker R. Dakhil
- Cancer Center of Kansas, 818 N Emporia Ave, Wichita, KS 67214 USA
| | - Rex B. Mowat
- Toledo Clinic, 4235 Secor Rd, Toledo, OH 43623 USA
| | - John P. Kuebler
- Columbus Oncology Associates, 810 Jasonway Ave, Columbus, OH 43214 USA
| | - George P. Kim
- Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 USA
| | | | - John Hornberger
- Cedar Associates LLC, 3715 Haven Avenue, Suite 100, Menlo Park, CA 94025 USA
- Stanford University School of Medicine, 291 Campus Dr, Stanford, CA 94305 USA
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Abstract
Colorectal cancer (CRC) is the third most common non-skin cancer diagnosed in men and women in the USA and worldwide. While it has been clearly established that screening for CRC, using a variety of methods, is cost effective and has a significant impact on overall survival, screening rates have proven to be sub-optimal. It has been long conjectured that a simple blood-based test, with a specimen drawn at a routine doctor's office visit, would encourage those individuals who have refused or ignored screening recommendations to undergo screening. This article reviews the currently available blood-based screening tests for CRC, including the ColonSentry™ messenger RNA (mRNA) expression panel and the SEPT9 methylated DNA test, and explores newer biomarkers that are near clinical implementation. Also discussed are additional applications for blood-based CRC testing, such as assessing prognosis, disease surveillance, and expansion of screening tests to high-risk populations, such as the estimated 1.4 million individuals in the USA with inflammatory bowel disease.
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Affiliation(s)
- Karen A Heichman
- Oncology Technology Development and Licensing, ARUP Laboratories Inc., 500 Chipeta Way, Mail stop #209, Salt Lake City, UT, 84108, USA,
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69
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Howard DH, Guy GP, Ekwueme DU. Eliminating cost-sharing requirements for colon cancer screening in Medicare. Cancer 2014; 120:3850-2. [PMID: 25302786 DOI: 10.1002/cncr.29093] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 09/05/2014] [Accepted: 09/09/2014] [Indexed: 11/07/2022]
Abstract
Medicare beneficiaries do not have to pay for screening colonoscopies but must pay coinsurance if a polyp is removed via polypectomy. Likewise, beneficiaries do not have to pay for fecal occult blood tests but are liable for cost-sharing for diagnostic colonoscopies after a positive test. Legislative and regulatory requirements related to colorectal cancer screening are described, and on the basis of Medicare claims, it is estimated that Medicare spending would increase by $48 million annually if Medicare were to waive cost-sharing requirements for these services. The economic impact on Medicare if beneficiaries were not responsible for any cost-sharing requirements related to colorectal cancer screening services is described.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Rollins School of Public Health and Winship Cancer Center, Emory University, Atlanta, Georgia
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Colorectal testing utilization and payments in a large cohort of commercially insured US adults. Am J Gastroenterol 2014; 109:1513-25. [PMID: 24980877 DOI: 10.1038/ajg.2014.64] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 02/18/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Screening decreases colorectal cancer (CRC) mortality. The national press has scrutinized colonoscopy charges. Little systematic evidence exists on colorectal testing and payments among commercially insured persons. Our aim was to characterize outpatient colorectal testing utilization and payments among commercially insured US adults. METHODS We conducted an observational cohort study of outpatient colorectal test utilization rates, indications, and payments among 21 million 18-64-year-old employees and dependants with noncapitated group health insurance provided by 160 self-insured employers in the 2009 Truven MarketScan Databases. RESULTS Colonoscopy was the predominant colorectal test. Among 50-64-year olds, 12% underwent colonoscopy in 1 year. Most fecal tests and colonoscopies were associated with screening/surveillance indications. Testing rates were higher in women, and increased with age. Mean payments for fecal occult blood and immunochemical tests were $5 and $21, respectively. Colonoscopy payments varied between and within sites of service. Mean payments for diagnostic colonoscopy in an office, outpatient hospital facility, and ambulatory surgical center were $586 (s.d. $259), $1,400 (s.d. $681), and $1,074 (s.d. $549), respectively. Anesthesia and pathology services accompanied 35 and 52% of colonoscopies, with mean payments of $494 (s.d. $354) and $272 (s.d. $284), respectively. Mean payments for the most prevalent colonoscopy codes were 1.4- to 1.9-fold the average Medicare payments. CONCLUSIONS Most outpatient colorectal testing among commercially insured adults was associated with screening or surveillance. Payments varied widely across sites of service, and payments for anesthesia and pathology services contributed substantially to total payments. Cost-effectiveness analyses of CRC screening have relied on Medicare payments as proxies for costs, but cost-effectiveness may differ when analyzed from the perspectives of Medicare or commercial insurers.
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71
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Ma GK, Ladabaum U. Personalizing colorectal cancer screening: a systematic review of models to predict risk of colorectal neoplasia. Clin Gastroenterol Hepatol 2014; 12:1624-34.e1. [PMID: 24534546 DOI: 10.1016/j.cgh.2014.01.042] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 01/23/2014] [Accepted: 01/23/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A valid risk prediction model for colorectal neoplasia would allow patients to be screened for colorectal cancer (CRC) on the basis of risk. We performed a systematic review of studies reporting risk prediction models for colorectal neoplasia. METHODS We conducted a systematic search of MEDLINE, Scopus, and Cochrane Library databases from January 1990 through March 2013 and of references in identified studies. Case-control, cohort, and cross-sectional studies that developed or attempted to validate a model to predict risk of colorectal neoplasia were included. Two reviewers independently extracted data and assessed model quality. Model quality was considered to be good for studies that included external validation, fair for studies that included internal validation, and poor for studies with neither. RESULTS Nine studies developed a new prediction model, and 2 tested existing models. The models varied with regard to population, predictors, risk tiers, outcomes (CRC or advanced neoplasia), and range of predicted risk. Several included age, sex, smoking, a measure of obesity, and/or family history of CRC among the predictors. Quality was good for 6 models, fair for 2 models, and poor for 1 model. The tier with the largest population fraction (low, intermediate, or high risk) depended on the model. For most models that defined risk tiers, the risk difference between the highest and lowest tier ranged from 2-fold to 4-fold. Two models reached the 0.70 threshold for the C statistic, typically considered to indicate good discriminatory power. CONCLUSIONS Most current colorectal neoplasia risk prediction models have relatively weak discriminatory power and have not demonstrated generalizability. It remains to be determined how risk prediction models could inform CRC screening strategies.
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Affiliation(s)
- Gene K Ma
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Uri Ladabaum
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California.
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72
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Grootjans-van Kampen I, Engelfriet PM, van Baal PHM. Disease prevention: saving lives or reducing health care costs? PLoS One 2014; 9:e104469. [PMID: 25116681 PMCID: PMC4130534 DOI: 10.1371/journal.pone.0104469] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/11/2014] [Indexed: 11/18/2022] Open
Abstract
Background Disease prevention has been claimed to reduce health care costs. However, preventing lethal diseases increases life expectancy and, thereby, indirectly increases the demand for health care. Previous studies have argued that on balance preventing diseases that reduce longevity increases health care costs while preventing non-fatal diseases could lead to health care savings. The objective of this research is to investigate if disease prevention could result in both increased longevity and lower lifetime health care costs. Methods Mortality rates for Netherlands in 2009 were used to construct cause-deleted life tables. Data originating from the Dutch Costs of Illness study was incorporated in order to estimate lifetime health care costs in the absence of selected disease categories. We took into account that for most diseases health care expenditures are concentrated in the last year of life. Results Elimination of diseases that reduce life expectancy considerably increase lifetime health care costs. Exemplary are neoplasms that, when eliminated would increase both life expectancy and lifetime health care spending with roughly 5% for men and women. Costs savings are incurred when prevention has only a small effect on longevity such as in the case of mental and behavioural disorders. Diseases of the circulatory system stand out as their elimination would increase life expectancy while reducing health care spending. Conclusion The stronger the negative impact of a disease on longevity, the higher health care costs would be after elimination. Successful treatment of fatal diseases leaves less room for longevity gains due to effective prevention but more room for health care savings.
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Affiliation(s)
| | - Peter M. Engelfriet
- Centre for Prevention and Health Services Research, Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Pieter H. M. van Baal
- Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
- * E-mail:
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Kapidzic A, Grobbee EJ, Hol L, van Roon AH, van Vuuren AJ, Spijker W, Izelaar K, van Ballegooijen M, Kuipers EJ, van Leerdam ME. Attendance and yield over three rounds of population-based fecal immunochemical test screening. Am J Gastroenterol 2014; 109:1257-64. [PMID: 24980879 DOI: 10.1038/ajg.2014.168] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/25/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Fecal immunochemical test (FIT) screening for colorectal cancer (CRC) requires timely successive rounds for an optimal preventive effect. However, data on attendance and trend in yield over multiple rounds of FIT screening are limited. We therefore conducted a consecutive third round of FIT screening in a population-based CRC screening trial. METHODS Average-risk subjects aged 50-74 years were approached for three rounds of 1-sample FIT (OC-sensor) screening. Subjects with a hemoglobin level ≥50 ng/ml (≥10 μg Hb/g) feces were referred for colonoscopy. Subjects with a positive FIT in previous rounds were not re-invited for FIT screening. RESULTS In the first round, 7,501 subjects were invited. The participation rate was 62.6% in the first round, 63.2% in the second round, and 68.3% in the third round (P<0.001). In total, 73% (5,241/7,229) of all eligible subjects participated in at least one of three rounds. The positivity rate was significantly higher in the first (8.4%) round compared with the second (6.0%) and third (5.7%) screening rounds (P<0.001). The detection rate of advanced neoplasia (AN) declined from the first round to subsequent rounds (round 1: 3.3%; round 2: 1.9%; and round 3: 1.3%; P<0.001). The positive predictive value for AN was 40.7% in the first screening round, 33.2% in the second screening round, and 24.0% in the third screening round (P<0.001). CONCLUSIONS Repeated biennial FIT screening is acceptable with increased participation in successive screening rounds, and >70% of all eligible subjects participating at least once over three rounds. The decline in screen-detected AN over three screening rounds is compatible with a decreased prevalence of AN as a result of repeated FIT screening. These findings provide strong evidence for the effectiveness of FIT screening and stress the importance of ongoing research over multiple screening rounds.
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Affiliation(s)
- Atija Kapidzic
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Elisabeth J Grobbee
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Aafke Hc van Roon
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Wolfert Spijker
- Regional Organization for Population Screening South-West Netherlands, Rotterdam, The Netherlands
| | - Kirsten Izelaar
- Regional Organization for Population Screening South-West Netherlands, Rotterdam, The Netherlands
| | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Joranger P, Nesbakken A, Hoff G, Sorbye H, Oshaug A, Aas E. Modeling and validating the cost and clinical pathway of colorectal cancer. Med Decis Making 2014; 35:255-65. [PMID: 25073464 DOI: 10.1177/0272989x14544749] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cancer is a major cause of morbidity and mortality, and colorectal cancer (CRC) is the third most common cancer in the world. The estimated costs of CRC treatment vary considerably, and if CRC costs in a model are based on empirically estimated total costs of stage I, II, III, or IV treatments, then they lack some flexibility to capture future changes in CRC treatment. The purpose was 1) to describe how to model CRC costs and survival and 2) to validate the model in a transparent and reproducible way. METHODS We applied a semi-Markov model with 70 health states and tracked age and time since specific health states (using tunnels and 3-dimensional data matrix). The model parameters are based on an observational study at Oslo University Hospital (2049 CRC patients), the National Patient Register, literature, and expert opinion. The target population was patients diagnosed with CRC. The model followed the patients diagnosed with CRC from the age of 70 until death or 100 years. The study focused on the perspective of health care payers. RESULTS The model was validated for face validity, internal and external validity, and cross-validity. The validation showed a satisfactory match with other models and empirical estimates for both cost and survival time, without any preceding calibration of the model. CONCLUSIONS The model can be used to 1) address a range of CRC-related themes (general model) like survival and evaluation of the cost of treatment and prevention measures; 2) make predictions from intermediate to final outcomes; 3) estimate changes in resource use and costs due to changing guidelines; and 4) adjust for future changes in treatment and trends over time. The model is adaptable to other populations.
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Affiliation(s)
- Paal Joranger
- Norwegian University of Life Science, Ås, Norway/Oslo and Akershus University College of Applied Sciences, Oslo, Norway (PJ)
| | - Arild Nesbakken
- Oslo University Hospital, Oslo, Norway/K.G. Jebsen Colorectal Cancer Research Centre, Oslo, Norway/University of Oslo, Oslo, Norway (AN)
| | - Geir Hoff
- Cancer Registry of Norway/University of Oslo/Telemark Hospital, Skien, Norway (GH)
| | | | - Arne Oshaug
- Oslo and Akershus University College of Applied Sciences, Oslo, Norway (AO)
| | - Eline Aas
- University of Oslo, Oslo, Norway (EA)
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Wheeler SB, Kuo TM, Goyal RK, Meyer AM, Hassmiller Lich K, Gillen EM, Tyree S, Lewis CL, Crutchfield TM, Martens CE, Tangka F, Richardson LC, Pignone MP. Regional variation in colorectal cancer testing and geographic availability of care in a publicly insured population. Health Place 2014; 29:114-23. [PMID: 25063908 DOI: 10.1016/j.healthplace.2014.07.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 06/25/2014] [Accepted: 07/01/2014] [Indexed: 12/15/2022]
Abstract
Despite its demonstrated effectiveness, colorectal cancer (CRC) testing is suboptimal, particularly in vulnerable populations such as those who are publicly insured. Prior studies provide an incomplete picture of the importance of the intersection of multilevel factors affecting CRC testing across heterogeneous geographic regions where vulnerable populations live. We examined CRC testing across regions of North Carolina by using population-based Medicare and Medicaid claims data from disabled individuals who turned 50 years of age during 2003-2008. We estimated multilevel models to examine predictors of CRC testing, including distance to the nearest endoscopy facility, county-level endoscopy procedural rates, and demographic and community contextual factors. Less than 50% of eligible individuals had evidence of CRC testing; men, African-Americans, Medicaid beneficiaries, and those living furthest away from endoscopy facilities had significantly lower odds of CRC testing, with significant regional variation. These results can help prioritize intervention strategies to improve CRC testing among publicly insured, disabled populations.
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Affiliation(s)
- Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA.
| | - Tzy-Mey Kuo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Ravi K Goyal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Anne-Marie Meyer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA
| | - Emily M Gillen
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA
| | - Seth Tyree
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Carmen L Lewis
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, 5045 Old Clinic Building, CB#7110, Chapel Hill, NC 27599-5039, USA
| | - Trisha M Crutchfield
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA
| | - Christa E Martens
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Florence Tangka
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Lisa C Richardson
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Michael P Pignone
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA; Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, 5045 Old Clinic Building, CB#7110, Chapel Hill, NC 27599-5039, USA
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76
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den Hoed CM, Isendoorn K, Klinkhamer W, Gupta A, Kuipers EJ. The societal gain of medical development and innovation in gastroenterology. United European Gastroenterol J 2014; 1:335-45. [PMID: 24917981 DOI: 10.1177/2050640613502337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 07/29/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Gastroenterology has over the past 30 years evolved very rapidly. The societal benefits to which this has led are incompletely determined, yet form a mandate to determine the need for future innovations and further development of the field. A more thorough understanding of societal benefits may help to determine future goals and improve decision making. AIMS The objective of this article is to determine the societal gains of medical innovations in the field of gastroenterology in the past and future, using peptic ulcer disease as an example of past innovation and the implementation of colorectal cancer screening as an illustration of future gains. METHODS Literature searches were performed for data on peptic ulcer and colorectal cancer epidemiology, treatment outcomes, and costs. National and governmental databases in the Netherlands were searched to obtain the input for calculations of quality-adjusted life years (QALYs), health-adjusted life expectancy (HALE), and the corresponding societal benefit. RESULTS Since 1980 the improvements in peptic ulcer treatment have had a limited impact on life expectancy, rising from 83.6 years to 83.7 years, but have led to a yearly gain of 46,000 QALYs, caused by improved quality of life. These developments in the field of peptic ulcer translated into a yearly gain of 1.8 billion to 7.8 billion euros in 2008 compared with the 1980s. Mortality due to colorectal cancer is high, with 21.6 deaths per 100,000 per year in the Netherlands (European Standardized Rate (ESR)). The future implementation of a nationwide call-recall colorectal cancer screening by means of biennial fecal immunochemical testing (FIT) is expected to result in a 50%-80% mortality reduction and thus a gain of an estimated 35,000 life years per year, corresponding to 26,000 QALYs per year. The effects of the implementation of FIT screening can be translated to a future societal gain of 1.0 billion to 4.4 billion euro. CONCLUSIONS The innovations and developments in the field of gastroenterology have led to significant societal gains in the past three decades. This process will continue in the near future as a result of further developments. These calculations provide a template for calculations on the need for specialist training as well as research and implementation of new developments in our field.
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Affiliation(s)
| | | | | | - Anshu Gupta
- Gupta Strategists, Ophemert, the Netherlands
| | - Ernst J Kuipers
- Departments of Gastroenterology and Hepatology ; Departments of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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Green BB, Coronado GD, Devoe JE, Allison J. Navigating the murky waters of colorectal cancer screening and health reform. Am J Public Health 2014; 104:982-6. [PMID: 24825195 DOI: 10.2105/ajph.2014.301877] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The Affordable Care Act (ACA) mandates that both Medicaid and insurance plans cover life-saving preventive services recommended by the US Preventive Services Task Force, including colorectal cancer (CRC) screening and choice between colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT). People who choose FOBT or sigmoidoscopy as their initial test could face high, unexpected, out-of-pocket costs because the mandate does not cover needed follow-up colonoscopies after positive tests. Some people will have no coverage for any CRC screening because of lack of state participation in the ACA or because they do not qualify (e.g., immigrant workers). Existing disparities in CRC screening and mortality will worsen if policies are not corrected to fully cover both initial and follow-up testing.
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Affiliation(s)
- Beverly B Green
- Beverly B. Green is with the Group Health Research Institute and the Group Health Cooperative, Seattle, WA. Gloria D. Coronado is with the Center for Health Research, Kaiser Permanente Northwest, Portland, OR. Jennifer E. Devoe is with the Department of Family Medicine, Oregon Health and Science University, and the OCHIN Practice-Based Research Network, Portland. James Allison is clinical professor of medicine emeritus, Division of Gastroenterology, University of California, San Francisco and emeritus researcher, Kaiser Division of Research, San Francisco
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78
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Guy GP, Richardson LC, Pignone MP, Plescia M. Costs and benefits of an organized fecal immunochemical test-based colorectal cancer screening program in the United States. Cancer 2014; 120:2308-15. [PMID: 24737634 DOI: 10.1002/cncr.28724] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/25/2014] [Accepted: 03/11/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Despite clear recommendations and evidence linking colorectal cancer screening to lower incidence and mortality, > 40% of adults are not up to date with screening. Existing domestic and international models of organized cancer screening programs have been effective in increasing screening rates. Implementing an organized, evidence-based, national screening program may be an effective approach to increasing screening rates. METHODS In the current study, the authors estimated the initial investment required and the cost per person screened of a nationwide fecal immunochemical test (FIT)-based colorectal cancer screening program among adults aged 50 years to 75 years. RESULTS The initial additional investment required was estimated at $277.9 to $318.2 million annually, with an estimated 8.7 to 9.4 million individuals screened at a cost of $32 to $39 per person screened. The program was estimated to prevent 2900 to 3100 deaths annually. CONCLUSIONS The results of the current study indicate that implementing a national screening program would make a substantial public health impact at a moderate cost per person screened. Results from this analysis may provide useful information for understanding the public health benefit of an organized screening delivery system and the potential resources required to implement a nationwide colorectal cancer screening program, and help guide decisions about program planning, design, and implementation.
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Affiliation(s)
- Gery P Guy
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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79
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van Dam L, Bretthauer M. Ethical issues in colorectal cancer screening. Best Pract Res Clin Gastroenterol 2014; 28:315-26. [PMID: 24810192 DOI: 10.1016/j.bpg.2014.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/02/2014] [Indexed: 02/07/2023]
Abstract
In many countries, colorectal cancer screening is currently an established population screening program due to the evidence on its reduction of colorectal cancer mortality. There is general consensus that colorectal cancer screening meets the screening criteria as proposed by Wilson and Jungner. However, as for all population screening programs, colorectal cancer screening also has disadvantages and thereby entails ethical issues. There are the general issues concerning the introduction of screening programs (e.g. medicalization, overdiagnosis and overtreatment, information provision to screenees), evaluation of cancer screening programs (e.g. lead time and length bias), chosen screening method (e.g. false-positive and false-negative test results, reduction of all-cause mortality, choice between different screening methods). The different colorectal cancer screening methods and the ethical issues concerning colorectal cancer screening will be discussed in this review.
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Affiliation(s)
- Leonie van Dam
- Department of Gastroenterology and Hepatology, University Medical Centre Rotterdam, The Netherlands; Department of Medical Ethics and Philosophy, University Medical Centre Rotterdam, The Netherlands.
| | - Michael Bretthauer
- Institute of Health and Society, University of Oslo, Oslo, Norway; Department of Transplantation Medicine, Section of Gastroenterology, Oslo University Hospital, Oslo, Norway.
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80
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Regge D, Iussich G, Senore C, Correale L, Hassan C, Bert A, Montemezzi S, Segnan N. Population screening for colorectal cancer by flexible sigmoidoscopy or CT colonography: study protocol for a multicenter randomized trial. Trials 2014; 15:97. [PMID: 24678896 PMCID: PMC3977672 DOI: 10.1186/1745-6215-15-97] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 10/31/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most prevalent type of cancer in Europe. A single flexible sigmoidoscopy (FS) screening at around the age of 60 years prevents about one-third of CRC cases. However, FS screens only the distal colon, and thus mortality from proximal CRC is unaffected. Computed tomography colonography (CTC) is a highly accurate examination that allows assessment of the entire colon. However, the benefit of CTC testing as a CRC screening test is uncertain. We designed a randomized trial to compare participation rate, detection rates, and costs between CTC (with computer-aided detection) and FS as primary tests for population-based screening. METHODS/DESIGN An invitation letter to participate in a randomized screening trial comparing CTC versus FS will be mailed to a sample of 20,000 people aged 58 or 60 years, living in the Piedmont region and the Verona district of Italy. Individuals with a history of CRC, adenomas, inflammatory bowel disease, or recent colonoscopy, or with two first-degree relatives with CRC will be excluded from the study by their general practitioners. Individuals responding positively to the invitation letter will be then randomized to the intervention group (CTC) or control group (FS), and scheduled for the screening procedure. The primary outcome parameter of this part of the trial is the difference in advanced neoplasia detection between the two screening tests. Secondary outcomes are cost-effectiveness analysis, referral rates for colonoscopy induced by CTC versus FS, and the expected and perceived burden of the procedures. To compare participation rates for CTC versus FS, 2,000 additional eligible subjects will be randomly assigned to receive an invitation for screening with CTC or FS. In the CTC arm, non-responders will be offered fecal occult blood test (FOBT) as alternative screening test, while in the FS arm, non-responders will receive an invitation letter to undergo screening with either FOBT or CTC. Data on reasons for participation and non-participation will also be collected. DISCUSSION This study will provide reliable information concerning benefits and risks of the adoption of CTC as a mass screening intervention in comparison with FS. The trial will also evaluate the role of computer-aided detection in a screening setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01739608.
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Affiliation(s)
- Daniele Regge
- Radiology Unit, Institute for Cancer Research and Treatment, FPO, Strada Provinciale 142, Candiolo 10060, Italy
| | - Gabriella Iussich
- Radiology Unit, Institute for Cancer Research and Treatment, FPO, Strada Provinciale 142, Candiolo 10060, Italy
| | - Carlo Senore
- CPO Piemonte and AO ‘City of Health and Science,’ SC Epidemiologia dei Tumori, Turin, Italy
| | | | - Cesare Hassan
- Department of Radiological Sciences Oncology and Pathology, University of Rome La Sapienza, Rome, Italy
| | | | | | - Nereo Segnan
- CPO Piemonte and AO ‘City of Health and Science,’ SC Epidemiologia dei Tumori, Turin, Italy
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Filipova-Neumann L, Hoy M. Managing genetic tests, surveillance, and preventive medicine under a public health insurance system. JOURNAL OF HEALTH ECONOMICS 2014; 34:31-41. [PMID: 24463140 DOI: 10.1016/j.jhealeco.2013.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 11/12/2013] [Accepted: 12/03/2013] [Indexed: 06/03/2023]
Abstract
There is a prospect in the medium to long term future of substantial advancements in the understanding of the relationship between disease and genetics. We consider the implications of increased information from genetic tests about predisposition to diseases from the perspective of managing health care provision under a public health insurance scheme. In particular, we consider how such information may potentially improve the targeting of medical surveillance (or prevention) activities to improve the chances of early detection of disease onset. We show that the moral hazard implications inherent in surveillance and prevention decisions that are chosen to be privately rather than socially optimal may be exacerbated by increased information about person-specific predisposition to disease.
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Affiliation(s)
- Lilia Filipova-Neumann
- Faculty of Business Administration and Economics, University of Augsburg, Universitätsstr. 2, 86159 Augsburg, Deutschland
| | - Michael Hoy
- Department of Economics and Finance, University of Guelph, Guelph, Ontario N1G 2W1, Canada.
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Yabroff KR, Borowski L, Lipscomb J. Economic studies in colorectal cancer: challenges in measuring and comparing costs. J Natl Cancer Inst Monogr 2014; 2013:62-78. [PMID: 23962510 DOI: 10.1093/jncimonographs/lgt001] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Estimates of the costs associated with cancer care are essential both for assessing burden of disease at the population level and for conducting economic evaluations of interventions to prevent, detect, or treat cancer. Comparisons of cancer costs between health systems and across countries can improve understanding of the economic consequences of different health-care policies and programs. We conducted a structured review of the published literature on colorectal cancer (CRC) costs, including direct medical, direct nonmedical (ie, patient and caregiver time, travel), and productivity losses. We used MEDLINE to identify English language articles published between 2000 and 2010 and found 55 studies. The majority were conducted in the United States (52.7%), followed by France (12.7%), Canada (10.9%), the United Kingdom (9.1%), and other countries (9.1%). Almost 90% of studies estimated direct medical costs, but few studies estimated patient or caregiver time costs or productivity losses associated with CRC. Within a country, we found significant heterogeneity across the studies in populations examined, health-care delivery settings, methods for identifying incident and prevalent patients, types of medical services included, and analyses. Consequently, findings from studies with seemingly the same objective (eg, costs of chemotherapy in year following CRC diagnosis) are difficult to compare. Across countries, aggregate and patient-level estimates vary in so many respects that they are almost impossible to compare. Our findings suggest that valid cost comparisons should be based on studies with explicit standardization of populations, services, measures of costs, and methods with the goal of comparability within or between health systems or countries. Expected increases in CRC prevalence and costs in the future highlight the importance of such studies for informing health-care policy and program planning.
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Affiliation(s)
- K Robin Yabroff
- Health Services and Economics Branch/Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Dr, 3E436, Rockville, MD 20850, USA.
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Lipscomb J, Yabroff KR, Hornbrook MC, Gigli A, Francisci S, Krahn M, Gatta G, Trama A, Ritzwoller DP, Durand-Zaleski I, Salloum R, Chawla N, Angiolini C, Crocetti E, Giusti F, Guzzinati S, Mezzetti M, Miccinesi G, Mariotto A. Comparing cancer care, outcomes, and costs across health systems: charting the course. J Natl Cancer Inst Monogr 2014; 2013:124-30. [PMID: 23962516 DOI: 10.1093/jncimonographs/lgt011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, Rm 720, 1518 Clifton Road, NE, Atlanta, GA 30322, USA.
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Haug U, Engel S, Verheyen F, Linder R. Estimating colorectal cancer treatment costs: a pragmatic approach exemplified by health insurance data from Germany. PLoS One 2014; 9:e88407. [PMID: 24586324 PMCID: PMC3929363 DOI: 10.1371/journal.pone.0088407] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/05/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The cost of colorectal cancer (CRC) treatment is a crucial parameter to inform cost-effectiveness analyses on CRC screening but it is not readily available and therefore often lacking. We aimed to elaborate and exemplify a pragmatic approach to estimate CRC treatment cost based on health insurance data from Germany. METHODS We included two groups of persons who were continuously health-insured between 2005-2010: A) Cases: Persons with a hospital discharge diagnosis of CRC (ICD C18-C20) between 2007-2010 and no such a diagnosis between 2005-2006 (to focus on incident CRC cases); B) Controls: Persons without a diagnosis of CRC during the observation period, matched to CRC cases by age and sex (matching factor: 1∶5). We considered in-patient, out-patient and drug costs and calculated incremental costs as the difference in means between cases and controls. We divided costs into three phases of care (initial, intermediate and end-of-life phase). RESULTS The initial, the intermediate and the end-of-life phase included 12,792, 5,280, and 3,779 CRC cases, respectively, and 63,960, 26,400, and 18,895 controls. The mean incremental costs--annualized for each phase--were €26,000, €2,300, and €51,700, respectively. The costs of the initial phase of care were higher for rectal than for colon cancer. Annualized stage-specific cost estimates ranged from €15,000 to €21,300 for early stages and from €29,800 to €35,000 for late stages. CONCLUSION This pragmatic and feasible approach provided plausible estimates of CRC treatment costs in Germany; being transferable to other settings, it may thus facilitate to weigh up potential savings in treatment costs against the resources required for CRC control programs in various countries.
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Affiliation(s)
- Ulrike Haug
- Epidemiological Cancer Registry Baden-Wuerttemberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
- * E-mail:
| | - Susanne Engel
- WINEG – Scientific Institute of the Techniker Krankenkasse (TK) for Benefit and Efficiency in Health Care, Hamburg, Germany
| | - Frank Verheyen
- WINEG – Scientific Institute of the Techniker Krankenkasse (TK) for Benefit and Efficiency in Health Care, Hamburg, Germany
| | - Roland Linder
- WINEG – Scientific Institute of the Techniker Krankenkasse (TK) for Benefit and Efficiency in Health Care, Hamburg, Germany
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Ventura L, Mantellini P, Grazzini G, Castiglione G, Buzzoni C, Rubeca T, Sacchettini C, Paci E, Zappa M. The impact of immunochemical faecal occult blood testing on colorectal cancer incidence. Dig Liver Dis 2014; 46:82-6. [PMID: 24011791 DOI: 10.1016/j.dld.2013.07.017] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 06/26/2013] [Accepted: 07/24/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND The efficacy of colorectal cancer screening based on faecal immunochemical test, in terms of reduction of colorectal cancer incidence, is under debate. In the district of Florence, an organized screening programme based on faecal immunochemical test has been running since the early 1990s. The aim of this study was to compare the risk of developing colorectal cancer for subjects undergoing faecal immunochemical test with those who did not undergo the test in the same period. METHODS Two cohorts were analyzed: subjects who underwent an initial faecal immunochemical test between 1993 and 1999 ("attenders"), and unscreened residents in the same municipalities invited to perform the faecal immunochemical test in the same period ("non-attenders"). Kaplan-Meier and Cox regression analysis were performed to evaluate the risk of developing colorectal cancer. RESULTS The attenders' and non-attenders' cohorts included 6961 and 26,285 subjects, respectively. Cox analysis showed a reduction in colorectal cancer incidence of 22% in the attenders' compared to the non-attenders' cohort (hazard ratio = 0.78, 95% Confidence Interval: 0.65-0.93). CONCLUSION Our results support the hypothesis that screening based on a single faecal immunochemical test every 2 years produces a significant decrease in colorectal cancer incidence after an average follow-up observation period of 11 years.
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Affiliation(s)
| | | | | | | | | | - Tiziana Rubeca
- Cancer Prevention and Research Institute, Florence, Italy
| | | | - Eugenio Paci
- Cancer Prevention and Research Institute, Florence, Italy
| | - Marco Zappa
- Cancer Prevention and Research Institute, Florence, Italy.
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Neerincx M, Buffart TE, Mulder CJJ, Meijer GA, Verheul HMW. The future of colorectal cancer: implications of screening. Gut 2013; 62:1387-9. [PMID: 23749605 DOI: 10.1136/gutjnl-2013-305023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Maarten Neerincx
- Department of Medical Oncology, VU University Medical Center, , Amsterdam, The Netherlands
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Dinh T, Ladabaum U, Alperin P, Caldwell C, Smith R, Levin TR. Health benefits and cost-effectiveness of a hybrid screening strategy for colorectal cancer. Clin Gastroenterol Hepatol 2013; 11:1158-66. [PMID: 23542330 DOI: 10.1016/j.cgh.2013.03.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 03/05/2013] [Accepted: 03/06/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) screening guidelines recommend screening schedules for each single type of test except for concurrent sigmoidoscopy and fecal occult blood test (FOBT). We investigated the cost-effectiveness of a hybrid screening strategy that was based on a fecal immunological test (FIT) and colonoscopy. METHODS We conducted a cost-effectiveness analysis by using the Archimedes Model to evaluate the effects of different CRC screening strategies on health outcomes and costs related to CRC in a population that represents members of Kaiser Permanente Northern California. The Archimedes Model is a large-scale simulation of human physiology, diseases, interventions, and health care systems. The CRC submodel in the Archimedes Model was derived from public databases, published epidemiologic studies, and clinical trials. RESULTS A hybrid screening strategy led to substantial reductions in CRC incidence and mortality, gains in quality-adjusted life years (QALYs), and reductions in costs, comparable with those of the best single-test strategies. Screening by annual FIT of patients 50-65 years old and then a single colonoscopy when they were 66 years old (FIT/COLOx1) reduced CRC incidence by 72% and gained 110 QALYs for every 1000 people during a period of 30 years, compared with no screening. Compared with annual FIT, FIT/COLOx1 gained 1400 QALYs/100,000 persons at an incremental cost of $9700/QALY gained and required 55% fewer FITs. Compared with FIT/COLOx1, colonoscopy at 10-year intervals gained 500 QALYs/100,000 at an incremental cost of $35,100/QALY gained but required 37% more colonoscopies. Over the ranges of parameters examined, the cost-effectiveness of hybrid screening strategies was slightly more sensitive to the adherence rate with colonoscopy than the adherence rate with yearly FIT. Uncertainties associated with estimates of FIT performance within a program setting and sensitivities for flat and right-sided lesions are expected to have significant impacts on the cost-effectiveness results. CONCLUSIONS In our simulation model, a strategy of annual or biennial FIT, beginning when patients are 50 years old, with a single colonoscopy when they are 66 years old, delivers clinical and economic outcomes similar to those of CRC screening by single-modality strategies, with a favorable impact on resources demand.
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Affiliation(s)
- Tuan Dinh
- Archimedes Inc, San Francisco, California 94105, USA.
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89
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Duffy MJ, Lamerz R, Haglund C, Nicolini A, Kalousová M, Holubec L, Sturgeon C. Tumor markers in colorectal cancer, gastric cancer and gastrointestinal stromal cancers: European group on tumor markers 2014 guidelines update. Int J Cancer 2013; 134:2513-22. [PMID: 23852704 PMCID: PMC4217376 DOI: 10.1002/ijc.28384] [Citation(s) in RCA: 224] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 06/25/2013] [Indexed: 02/06/2023]
Abstract
Biomarkers currently play an important role in the detection and management of patients with several different types of gastrointestinal cancer, especially colorectal, gastric, gastro-oesophageal junction (GOJ) adenocarcinomas and gastrointestinal stromal tumors (GISTs). The aim of this article is to provide updated and evidence-based guidelines for the use of biomarkers in the different gastrointestinal malignancies. Recommended biomarkers for colorectal cancer include an immunochemical-based fecal occult blood test in screening asymptomatic subjects ≥50 years of age for neoplasia, serial CEA levels in postoperative surveillance of stage II and III patients who may be candidates for surgical resection or systemic therapy in the event of distant metastasis occurring, K-RAS mutation status for identifying patients with advanced disease likely to benefit from anti-EGFR therapeutic antibodies and microsatellite instability testing as a first-line screen for subjects with Lynch syndrome. In advanced gastric or GOJ cancers, measurement of HER2 is recommended in selecting patients for treatment with trastuzumab. For patients with suspected GIST, determination of KIT protein should be used as a diagnostic aid, while KIT mutational analysis may be used for treatment planning in patients with diagnosed GISTs.
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Affiliation(s)
- M J Duffy
- Clinical Research Center, St Vincent's University Hospital, Dublin 4 and UCD School of Medicine and Medical Science, Conway Institute, University College Dublin, Dublin, Ireland
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90
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Luttjeboer J, Westra T, Wilschut J, Nijman H, Daemen T, Postma M. Cost–effectiveness of the prophylactic HPV vaccine: An application to the Netherlands taking non-cervical cancers and cross-protection into account. Vaccine 2013; 31:3922-7. [DOI: 10.1016/j.vaccine.2013.06.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 05/31/2013] [Accepted: 06/12/2013] [Indexed: 12/12/2022]
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91
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Abstract
Colorectal cancer represents a major cause of mortality in Western countries, and population-based colonoscopy screening is supported by official guidelines. A significant determinant of the cost of colonoscopy screening/surveillance is driven by polypectomy of diminutive (≤5 mm) lesions. When considering the low prevalence of advanced neoplasia within diminutive polyps, the additional cost of pathologic examination is mainly justified by the need to differentiate between precancerous adenomatous versus hyperplastic polyps. The aim of this review is to summarize the data supporting the clinical application of a resect and discard strategy, also addressing the potential pitfalls associated with this approach.
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92
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Ladabaum U, Allen J, Wandell M, Ramsey S. Colorectal cancer screening with blood-based biomarkers: cost-effectiveness of methylated septin 9 DNA versus current strategies. Cancer Epidemiol Biomarkers Prev 2013; 22:1567-76. [PMID: 23796793 DOI: 10.1158/1055-9965.epi-13-0204] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Screening reduces colorectal cancer mortality, but many persons remain unscreened. Screening with a blood test could improve screening rates. We estimated the comparative effectiveness and cost-effectiveness of colorectal cancer screening with emerging biomarkers, illustrated by a methylated Septin 9 DNA plasma assay ((m)SEPT9), versus established strategies. METHODS We conducted a cost-utility analysis using a validated decision analytic model comparing (m)SEPT9, fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), sigmoidoscopy, and colonoscopy, projecting lifetime benefits and costs. RESULTS In the base case, (m)SEPT9 decreased colorectal cancer incidence by 35% to 41% and colorectal cancer mortality by 53% to 61% at costs of $8,400 to $11,500/quality-adjusted life year gained versus no screening. All established screening strategies were more effective than (m)SEPT9. FIT was cost saving, dominated (m)SEPT9, and was preferred among all the alternatives. Screening uptake and longitudinal adherence rates over time strongly influenced the comparisons between strategies. At the population level, (m)SEPT9 yielded incremental benefit at acceptable costs when it increased the fraction of the population screened more than it was substituted for other strategies. CONCLUSIONS (m)SEPT9 seems to be effective and cost-effective compared with no screening. To be cost-effective compared with established strategies, (m)SEPT9 or blood-based biomarkers with similar test performance characteristics would need to achieve substantially higher uptake and adherence rates than the alternatives. It remains to be proven whether colorectal cancer screening with a blood test can improve screening uptake or long-term adherence compared with established strategies. IMPACT Our study offers insights into the potential role of colorectal cancer screening with blood-based biomarkers.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305-5187, USA.
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93
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Regula J, Kaminski MF. Endoscopic colorectal cancer screening provides long-lasting effect. United European Gastroenterol J 2013; 1:160-1. [PMID: 24917954 DOI: 10.1177/2050640613491255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jaroslaw Regula
- Medical Center for Postgraduate Education, Warsaw, Poland ; Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Michal F Kaminski
- Medical Center for Postgraduate Education, Warsaw, Poland ; Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
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94
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Goede SL, van Roon AHC, Reijerink JCIY, van Vuuren AJ, Lansdorp-Vogelaar I, Habbema JDF, Kuipers EJ, van Leerdam ME, van Ballegooijen M. Cost-effectiveness of one versus two sample faecal immunochemical testing for colorectal cancer screening. Gut 2013; 62:727-34. [PMID: 22490518 PMCID: PMC3618685 DOI: 10.1136/gutjnl-2011-301917] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The sensitivity and specificity of a single faecal immunochemical test (FIT) are limited. The performance of FIT screening can be improved by increasing the screening frequency or by providing more than one sample in each screening round. This study aimed to evaluate if two-sample FIT screening is cost-effective compared with one-sample FIT. DESIGN The MISCAN-colon microsimulation model was used to estimate costs and benefits of strategies with either one or two-sample FIT screening. The FIT cut-off level varied between 50 and 200 ng haemoglobin/ml, and the screening schedule was varied with respect to age range and interval. In addition, different definitions for positivity of the two-sample FIT were considered: at least one positive sample, two positive samples, or the mean of both samples being positive. RESULTS Within an exemplary screening strategy, biennial FIT from the age of 55-75 years, one-sample FIT provided 76.0-97.0 life-years gained (LYG) per 1000 individuals, at a cost of € 259,000-264,000 (range reflects different FIT cut-off levels). Two-sample FIT screening with at least one sample being positive provided 7.3-12.4 additional LYG compared with one-sample FIT at an extra cost of € 50,000-59,000. However, when all screening intervals and age ranges were considered, intensifying screening with one-sample FIT provided equal or more LYG at lower costs compared with two-sample FIT. CONCLUSION If attendance to screening does not differ between strategies it is recommended to increase the number of screening rounds with one-sample FIT screening, before considering increasing the number of FIT samples provided per screening round.
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Affiliation(s)
- S Lucas Goede
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, Rotterdam 3000 CA, The Netherlands.
| | - Aafke H C van Roon
- Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | | | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J Dik F Habbema
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands,Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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95
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DeBarros M, Steele SR. Colorectal cancer screening in an equal access healthcare system. J Cancer 2013; 4:270-80. [PMID: 23459768 PMCID: PMC3584840 DOI: 10.7150/jca.5833] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 02/13/2013] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The military health system (MHS) a unique setting to analyze implementation programs as well as outcomes for colorectal cancer (CRC). Here we look at the efficacy of different CRC screening methods, attributes and results within the MHS, and current barriers to increase compliance. MATERIALS AND METHODS A literature search was conducted utilizing PubMed and the Cochrane library. Key-word combinations included colorectal cancer screening, racial disparity, risk factors, colorectal cancer, screening modalities, and randomized control trials. Directed searches were also performed of embedded references. RESULTS Despite screening guidelines from several national organizations, extensive barriers to widespread screening remain, especially for minority populations. These barriers are diverse, ranging from education and access problems to personal beliefs. Screening rates in MHS have been reported to be generally higher at 71% compared to national averages of 50-65%. CONCLUSION CRC screening can be highly effective at improving detection of both pre-malignant and early cancers. Improved patient education and directed efforts are needed to improve CRC screening both nationally and within the MHS.
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Affiliation(s)
| | - Scott R. Steele
- Department of Surgery, Madigan Healthcare System, Tacoma, Washington, USA
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96
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Abstract
Simulation modeling is extensively applied to CT colonography (CTC) to define its long-term efficacy and cost-effectiveness for colorectal cancer (CRC) screening. CTC is effective in reducing CRC incidence and mortality (40%-77% and 58%-84%, respectively). Several factors may explain this variability. CTC is cost-effective compared with no screening, indicating that it represents an attractive test noncompliance with the available options. CTC needs to achieve a higher attendance rate or cost less than colonoscopy to be cost-effective relative to colonoscopy. Fortunately, both conditions appear to be achievable if CTC becomes a widely utilized and reimbursed screening tool.
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Affiliation(s)
- Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Roma 00153, Italy.
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97
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Abstract
The first evidence that screening for colorectal cancer (CRC) could effectively reduce mortality dates back 20 years. However, actual population screening has, in many countries, halted at the level of individual testing and discussions on differences between screening tests. With a wealth of new evidence from various community-based studies looking at test uptake, screening-programme organization and the importance of quality assurance, population screening for CRC is now moving into a new realm, promising better results in terms of reducing CRC-specific morbidity and mortality. Such a shift in the paradigm requires a change from opportunistic, individual testing towards organized population screening with comprehensive monitoring and full-programme quality assurance. To achieve this, a combination of factors--including test characteristics, uptake, screenee autonomy, costs and capacity--must be considered. Thus, evidence from randomized trials comparing different tests must be supplemented by studies of acceptance and uptake to obtain the full picture of the effectiveness (in terms of morbidity, mortality and cost) the different strategies have. In this Review, we discuss a range of screening modalities and describe the factors to be considered to achieve a truly effective population CRC screening programme.
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98
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Sharaf RN, Ladabaum U. Comparative effectiveness and cost-effectiveness of screening colonoscopy vs. sigmoidoscopy and alternative strategies. Am J Gastroenterol 2013; 108:120-32. [PMID: 23247579 DOI: 10.1038/ajg.2012.380] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Fecal occult blood testing (FOBT) and sigmoidoscopy are proven to decrease colorectal cancer (CRC) incidence and mortality. Sigmoidoscopy's benefit is limited to the distal colon. Observational data are conflicting regarding the degree to which colonoscopy affords protection against proximal CRC. Our aim was to explore the comparative effectiveness and cost-effectiveness of colonoscopy vs. sigmoidoscopy and alternative CRC screening strategies in light of the latest published data. METHODS We performed a contemporary cost-utility analysis using a Markov model validated against data from randomized controlled trials of FOBT and sigmoidoscopy. Persons at average CRC risk within the general US population were modeled. Screening strategies included those recommended by the United States (US) Preventive Services Task Force, including colonoscopy every 10 years (COLO), flexible sigmoidoscopy every 5 years (FS), annual fecal occult blood testing, annual fecal immunochemical testing (FIT), and the combination FS/FIT. The main outcome measures were quality-adjusted life-years (QALYs) and costs. RESULTS In the base case, FIT dominated other strategies. The advantage of FIT over FS and COLO was contingent on rates of uptake and adherence that are well above current US rates. Compared with FIT, FS and COLO both cost <$50,000/QALY gained when FIT per-cycle adherence was <50%. COLO cost $56,800/QALY gained vs. FS in the base case. COLO cost <$100,000/QALY gained vs. FS when COLO yielded a relative risk of proximal CRC of <0.5 vs. no screening. In probabilistic analyses, COLO was cost-effective vs. FS at a willingness-to-pay threshold of $100,000/QALY gained in 84% of iterations. CONCLUSIONS Screening colonoscopy may be cost-effective compared with FIT and sigmoidoscopy, depending on the relative rates of screening uptake and adherence and the protective benefit of colonoscopy in the proximal colon. Colonoscopy's cost-effectiveness compared with sigmoidoscopy is contingent on the ability to deliver ~50% protection against CRC in the proximal colon.
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Affiliation(s)
- Ravi N Sharaf
- Department of Gastroenterology, Department of Medicine, Hofstra University School of Medicine, North Shore-Long Island Jewish Health System, Manhasset, NY, USA
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99
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van Dam L, Kuipers EJ, Steyerberg EW, van Leerdam ME, de Beaufort ID. The price of autonomy: should we offer individuals a choice of colorectal cancer screening strategies? Lancet Oncol 2013; 14:e38-46. [DOI: 10.1016/s1470-2045(12)70455-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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100
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Hornberger J, Lyman GH, Chien R, Meropol NJ. A multigene prognostic assay for selection of adjuvant chemotherapy in patients with T3, stage II colon cancer: impact on quality-adjusted life expectancy and costs. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:1014-21. [PMID: 23244802 DOI: 10.1016/j.jval.2012.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 06/13/2012] [Accepted: 07/23/2012] [Indexed: 05/07/2023]
Abstract
OBJECTIVES Uncertainty exists regarding appropriate and affordable use of adjuvant chemotherapy in stage II colon cancer (T3, proficient DNA mismatch repair). This study aimed to estimate the effectiveness and costs from a US societal perspective of a multigene recurrence score (RS) assay for patients recently diagnosed with stage II colon cancer (T3, proficient DNA mismatch repair) eligible for adjuvant chemotherapy. METHODS RS was compared with guideline-recommended clinicopathological factors (tumor stage, lymph nodes examined, tumor grade, and lymphovascular invasion) by using a state-transition (Markov) lifetime model. Data were obtained from published literature, a randomized controlled trial (QUick And Simple And Reliable) of adjuvant chemotherapy, and rates of chemotherapy use from the National Cooperative Cancer Network Colon/Rectum Cancer Outcomes study. Life-years, quality-adjusted life expectancy, and lifetime costs were examined. RESULTS The RS is projected to reduce adjuvant chemotherapy use by 17% compared with current treatment patterns and to increase quality-adjusted life expectancy by an average of 0.035 years. Direct medical costs are expected to decrease by an average of $2971 per patient. The assay was cost saving for all subgroups of patients stratified by clinicopathologic factors. The most influential variables affecting treatment decisions were projected years of life remaining, recurrence score, and patients' disutilities associated with adjuvant chemotherapy. CONCLUSIONS Use of the multigene RS to assess recurrence risk after surgery in stage II colon cancer (T3, proficient DNA mismatch repair) may reduce the use of adjuvant chemotherapy without decreasing quality-adjusted life expectancy and be cost saving from a societal perspective. These findings need to be validated in additional cohorts, including studies of clinical practice as assay use diffuses into nonacademic settings.
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