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Westwood M, Corro Ramos I, Lang S, Luyendijk M, Zaim R, Stirk L, Al M, Armstrong N, Kleijnen J. Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: a systematic review and cost-effectiveness analysis. Health Technol Assess 2018. [PMID: 28643629 DOI: 10.3310/hta21330] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the third most common cancer in the UK. Presenting symptoms that can be associated with CRC usually have another explanation. Faecal immunochemical tests (FITs) detect blood that is not visible to the naked eye and may help to select patients who are likely to benefit from further investigation. OBJECTIVES To assess the effectiveness of FITs [OC-Sensor (Eiken Chemical Co./MAST Diagnostics, Tokyo, Japan), HM-JACKarc (Kyowa Medex/Alpha Laboratories Ltd, Tokyo, Japan), FOB Gold (Sentinel/Sysmex, Sentinel Diagnostics, Milan, Italy), RIDASCREEN Hb or RIDASCREEN Hb/Hp complex (R-Biopharm, Darmstadt, Germany)] for primary care triage of people with low-risk symptoms. METHODS Twenty-four resources were searched to March 2016. Review methods followed published guidelines. Summary estimates were calculated using a bivariate model or a random-effects logistic regression model. The cost-effectiveness analysis considered long-term costs and quality-adjusted life-years (QALYs) that were associated with different faecal occult blood tests and direct colonoscopy referral. Modelling comprised a diagnostic decision model, a Markov model for long-term costs and QALYs that were associated with CRC treatment and progression, and a Markov model for QALYs that were associated with no CRC. RESULTS We included 10 studies. Using a single sample and 10 µg Hb/g faeces threshold, sensitivity estimates for OC-Sensor [92.1%, 95% confidence interval (CI) 86.9% to 95.3%] and HM-JACKarc (100%, 95% CI 71.5% to 100%) indicated that both may be useful to rule out CRC. Specificity estimates were 85.8% (95% CI 78.3% to 91.0%) and 76.6% (95% CI 72.6% to 80.3%). Triage using FITs could rule out CRC and avoid colonoscopy in approximately 75% of symptomatic patients. Data from our systematic review suggest that 22.5-93% of patients with a positive FIT and no CRC have other significant bowel pathologies. The results of the base-case analysis suggested minimal difference in QALYs between all of the strategies; no triage (referral straight to colonoscopy) is the most expensive. Faecal immunochemical testing was cost-effective (cheaper and more, or only slightly less, effective) compared with no triage. Faecal immunochemical testing was more effective and costly than guaiac faecal occult blood testing, but remained cost-effective at a threshold incremental cost-effectiveness ratio of £30,000. The results of scenario analyses did not differ substantively from the base-case. Results were better for faecal immunochemical testing when accuracy of the guaiac faecal occult blood test (gFOBT) was based on studies that were more representative of the correct population. LIMITATIONS Only one included study evaluated faecal immunochemical testing in primary care; however, all of the other studies evaluated faecal immunochemical testing at the point of referral. Further, validation data for the Faecal haemoglobin, Age and Sex Test (FAST) score, which includes faecal immunochemical testing, showed no significant difference in performance between primary and secondary care. There were insufficient data to adequately assess FOB Gold, RIDASCREEN Hb or RIDASCREEN Hb/Hp complex. No study compared FIT assays, or FIT assays versus gFOBT; all of the data included in this assessment refer to the clinical effectiveness of individual FIT methods and not their comparative effectiveness. CONCLUSIONS Faecal immunochemical testing is likely to be a clinically effective and cost-effective strategy for triaging people who are presenting, in primary care settings, with lower abdominal symptoms and who are at low risk for CRC. Further research is required to confirm the effectiveness of faecal immunochemical testing in primary care practice and to compare the performance of different FIT assays. STUDY REGISTRATION This study is registered as PROSPERO CRD42016037723. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Isaac Corro Ramos
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Shona Lang
- Kleijnen Systematic Reviews Ltd, York, UK
| | - Marianne Luyendijk
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Remziye Zaim
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Lisa Stirk
- Kleijnen Systematic Reviews Ltd, York, UK
| | - Maiwenn Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Jos Kleijnen
- School for Public Health and Primary Care (Care and Public Health Research Institute), Maastricht University, Maastricht, the Netherlands
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van der Meulen MP, Lansdorp-Vogelaar I, Goede SL, Kuipers EJ, Dekker E, Stoker J, van Ballegooijen M. Colorectal Cancer: Cost-effectiveness of Colonoscopy versus CT Colonography Screening with Participation Rates and Costs. Radiology 2018; 287:901-911. [PMID: 29485322 DOI: 10.1148/radiol.2017162359] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Purpose To compare the cost-effectiveness of computed tomographic (CT) colonography and colonoscopy screening by using data on unit costs and participation rates from a randomized controlled screening trial in a dedicated screening setting. Materials and Methods Observed participation rates and screening costs from the Colonoscopy or Colonography for Screening, or COCOS, trial were used in a microsimulation model to estimate costs and quality-adjusted life-years (QALYs) gained with colonoscopy and CT colonography screening. For both tests, the authors determined optimal age range and screening interval combinations assuming a 100% participation rate. Assuming observed participation for these combinations, the cost-effectiveness of both tests was compared. Extracolonic findings were not included because long-term follow-up data are lacking. Results The participation rates for colonoscopy and CT colonography were 21.5% (1276 of 5924 invitees) and 33.6% (982 of 2920 invitees), respectively. Colonoscopy was more cost-effective in the screening strategies with one or two lifetime screenings, whereas CT colonography was more cost-effective in strategies with more lifetime screenings. CT colonography was the preferred test for willingness-to-pay-thresholds of €3200 per QALY gained and higher, which is lower than the Dutch willingness-to-pay threshold of €20 000. With equal participation, colonoscopy was the preferred test independent of willingness-to-pay thresholds. The findings were robust for most of the sensitivity analyses, except with regard to relative screening costs and subsequent participation. Conclusion Because of the higher participation rates, CT colonography screening for colorectal cancer is more cost-effective than colonoscopy screening. The implementation of CT colonography screening requires previous satisfactory resolution to the question as to how best to deal with extracolonic findings. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Miriam P van der Meulen
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Iris Lansdorp-Vogelaar
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - S Lucas Goede
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Ernst J Kuipers
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Evelien Dekker
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Jaap Stoker
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
| | - Marjolein van Ballegooijen
- From the Departments of Public Health (M.P.v.d.M., I.L.V., S.L.G., M.v.B.), Gastroenterology and Hepatology (E.J.K.), and Internal Medicine (E.J.K.), Erasmus Medical Centre, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology (E.D.) and Department of Radiology (J.S.), Academic Medical Center, Amsterdam, the Netherlands
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Gc VS, Suhrcke M, Hardeman W, Sutton S, Wilson ECF. Cost-Effectiveness and Value of Information Analysis of Brief Interventions to Promote Physical Activity in Primary Care. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:18-26. [PMID: 29304936 DOI: 10.1016/j.jval.2017.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 07/10/2017] [Accepted: 07/16/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Brief interventions (BIs) delivered in primary care have shown potential to increase physical activity levels and may be cost-effective, at least in the short-term, when compared with usual care. Nevertheless, there is limited evidence on their longer term costs and health benefits. OBJECTIVES To estimate the cost-effectiveness of BIs to promote physical activity in primary care and to guide future research priorities using value of information analysis. METHODS A decision model was used to compare the cost-effectiveness of three classes of BIs that have been used, or could be used, to promote physical activity in primary care: 1) pedometer interventions, 2) advice/counseling on physical activity, and (3) action planning interventions. Published risk equations and data from the available literature or routine data sources were used to inform model parameters. Uncertainty was investigated with probabilistic sensitivity analysis, and value of information analysis was conducted to estimate the value of undertaking further research. RESULTS In the base-case, pedometer interventions yielded the highest expected net benefit at a willingness to pay of £20,000 per quality-adjusted life-year. There was, however, a great deal of decision uncertainty: the expected value of perfect information surrounding the decision problem for the National Health Service Health Check population was estimated at £1.85 billion. CONCLUSIONS Our analysis suggests that the use of pedometer BIs is the most cost-effective strategy to promote physical activity in primary care, and that there is potential value in further research into the cost-effectiveness of brief (i.e., <30 minutes) and very brief (i.e., <5 minutes) pedometer interventions in this setting.
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Affiliation(s)
- Vijay Singh Gc
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Marc Suhrcke
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK; UKCRC Centre for Diet and Activity Research, University of Cambridge School of Clinical Medicine, Cambridge, UK; Centre for Health Economics, University of York, York, UK
| | - Wendy Hardeman
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Stephen Sutton
- Behavioural Science Group, Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Edward C F Wilson
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK; Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK; Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Naber SK, Kuntz KM, Henrikson NB, Williams MS, Calonge N, Goddard KA, Zallen DT, Ganiats TG, Webber EM, Janssens ACJ, van Ballegooijen M, Zauber AG, Lansdorp-Vogelaar I. Cost Effectiveness of Age-Specific Screening Intervals for People With Family Histories of Colorectal Cancer. Gastroenterology 2018; 154:105-116.e20. [PMID: 28964749 PMCID: PMC6104831 DOI: 10.1053/j.gastro.2017.09.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 08/18/2017] [Accepted: 09/18/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Relative risk of colorectal cancer (CRC) decreases with age among individuals with a family history of CRC. However, no screening recommendations specify less frequent screening with increasing age. We aimed to determine whether such a refinement would be cost effective. METHODS We determined the relative risk for CRC for individuals based on age and number of affected first-degree relatives (FDRs) using data from publications. For each number of affected FDRs, we used the Microsimulation Screening Analysis model to estimate costs and effects of colonoscopy screening strategies with different age ranges and intervals. Screening was then optimized sequentially, starting with the youngest age group, and allowing the interval of screening to change at certain ages. Strategies with an incremental cost effectiveness ratio below $100,000 per quality-adjusted life year were considered cost effective. RESULTS For people with 1 affected FDR (92% of those with a family history), screening every 3 years beginning at an age of 40 years is most cost effective. If no adenomas are found, the screening interval can gradually be extended to 5 and 7 years, at ages 45 and 55 years, respectively. From a cost-effectiveness perspective, individuals with more affected FDRs should start screening earlier and at shorter intervals. However, frequency can be reduced if no abnormalities are found. CONCLUSIONS Using a microsimulation model, we found that for individuals with a family history of CRC, it is cost effective to gradually increase the screening interval if several subsequent screening colonoscopies have negative results and no new cases of CRC are found in family members.
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Affiliation(s)
- Steffie K. Naber
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,Corresponding author
| | - Karen M. Kuntz
- Department of Health Policy & Management, University of Minnesota, Minneapolis, MN, United States
| | | | - Marc S. Williams
- Genomic Medicine Institute, Geisinger Health System, Danville, PA, United States
| | - Ned Calonge
- The Colorado Trust, Denver, CO, United States
| | - Katrina A.B. Goddard
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States
| | - Doris T. Zallen
- Department of Science and Technology in Society, VirginiaTech, Blacksberg, VA, United States
| | - Theodore G. Ganiats
- Agency for Healthcare Research and Quality, Rockville, MD United States,Dr. Ganiats is a Senior Staff Fellow at the Agency for Healthcare Research and Quality (AHRQ). The views expressed are those of the author and no official endorsement by AHRQ, the U.S. Department of Health and Human Services, or the Federal government is intended or should be inferred.
| | - Elizabeth M. Webber
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States
| | | | - Marjolein van Ballegooijen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ann G. Zauber
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Parker B, Buchanan J, Wordsworth S, Keshav S, George B, East JE. Surgery versus surveillance in ulcerative colitis patients with endoscopically invisible low-grade dysplasia: a cost-effectiveness analysis. Gastrointest Endosc 2017; 86:1088-1099.e5. [PMID: 28882578 DOI: 10.1016/j.gie.2017.08.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There is uncertainty regarding the optimal management of endoscopically invisible (flat) low-grade dysplasia in ulcerative colitis. Such a finding does not currently provide an automatic indication for colectomy; however, a recommendation of surveillance instead of surgery is controversial. The aim of this study was to determine the clinical and cost-effectiveness of colonoscopic surveillance versus colectomy for endoscopically invisible low-grade dysplasia of the colon in ulcerative colitis. METHODS A Markov model was used to evaluate the costs and health outcomes of surveillance and surgery over a 20-year timeframe. Outcomes evaluated were life years gained and quality-adjusted life years (QALYs). Cohorts of patients aged 25 to 75 were modeled, including estimates from a validated surgical risk calculator and considering none, 1, or both of 2 key comorbidities: heart failure and obstructive airway disease. RESULTS Surveillance is associated with more life years and QALYs compared with surgery from age 61 for those with no comorbidities, age 51 for those with 1 comorbidity and age 25 for those with 2 comorbidities. At the current United Kingdom National Institute for Health and Care Excellence threshold of $25,800 per QALY, ongoing surveillance was cost-effective at age 65 in those without comorbidities and at age 60 in those with either 1 or more comorbidities. CONCLUSIONS Surveillance can be recommended from age 65 for those with no comorbidities; however, in younger patients with typical postsurgical quality of life, colectomy may be more effective clinically and more cost-effective. The results were sensitive to the colorectal cancer incidence rate in patients under surveillance and to quality of life after surgery.
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Affiliation(s)
- Ben Parker
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Satish Keshav
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Bruce George
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - James E East
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Sjöström O, Lindholm L, Melin B. Colonoscopic surveillance - a cost-effective method to prevent hereditary and familial colorectal cancer. Scand J Gastroenterol 2017; 52:1002-1007. [PMID: 28587529 DOI: 10.1080/00365521.2017.1327615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Approximately 20-30% of all colorectal cancer (CRC) cases may have a familial contribution. The family history of CRC can be prominent (e.g., hereditary colorectal cancer (HCRC)) or more moderate (e.g., familial colorectal cancer (FCRC)). For family members at risk, colonoscopic surveillance is a well-established method to prevent both HCRC and FCRC, although the evidence for the exact procedures of the surveillance is limited. Surveillance can come at a high price if individuals are frequently examined, as this may result in unnecessary colonoscopies in relation to actual risk for CRC. This study analyses the cost-effectiveness of a surveillance programme implemented in the Northern Sweden Health Care Region. METHODS The study includes 259 individuals prospectively recorded in the colonoscopic surveillance programme registry at the Cancer Prevention Clinic, Umeå University Hospital. We performed a cost-utility analysis with a contrafactual design: we compared observed costs and loss of quality-adjusted life years (QALYs) due to CRC with the surveillance programme to an expected outcome without surveillance. The main measure was the incremental cost-effectiveness ratio (ICER) between surveillance and non-surveillance. Scenario analysis was used to explore uncertainty. RESULTS The ICER between surveillance and non-surveillance in the base model was 3596€/QALY. The ICER varied from -4620€ in the best-case scenario to 33,779€ in the worst-case scenario. CONCLUSION Colonoscopic surveillance is a very cost-effective method to prevent HCRC and FCRC compared to current thresholds for cost-effectiveness and other cancer preventive interventions.
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Affiliation(s)
- Olle Sjöström
- a Department of Radiation Sciences, Oncology , Umeå University , Umeå , Sweden
| | - Lars Lindholm
- b Department of Public Health and Clinical Medicine, Epidemiology and Global Health , Umeå University , Umeå , Sweden
| | - Beatrice Melin
- a Department of Radiation Sciences, Oncology , Umeå University , Umeå , Sweden
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Lee JY, Ock M, Jo MW, Son WS, Lee HJ, Kim SH, Kim HJ, Lee JL. Estimating utility weights and quality-adjusted life year loss for colorectal cancer-related health states in Korea. Sci Rep 2017; 7:5571. [PMID: 28717246 PMCID: PMC5514107 DOI: 10.1038/s41598-017-06004-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 06/05/2017] [Indexed: 02/07/2023] Open
Abstract
We aimed to assess utility weight of health states associated with colorectal cancer (CRC) that reflect the societal preference of the Korean population and to estimate the quality-adjusted life year (QALY) loss with CRC. We recruited 607 individuals from the Korean population; they were surveyed via face-to-face computer-assisted interviews. The participants evaluated each CRC-associated health state using standard gamble. Utility weight for each health state was calculated as the possibility of full health restoration. Moreover, we estimated total QALY loss due to CRC in Korean individuals aged ≥30 years in 2013. To calculate QALY due to morbidity, we yielded utility weights and used epidemiologic data of CRC on severity from the National Cancer Control Institute. QALY loss due to mortality was calculated using mortality of CRC and life expectancy data from the Korean Statistical Information Service. The highest and lowest utility weights were assigned to "adenomatous polyps" and "metastatic colon cancer", respectively. Total QALY loss due to CRC in Korea was 173,662; these patients were more likely to be men or be included in the 70-74-year age group. These utility weights may be useful for conducting cost-utility studies of cancer screening for CRC and for measuring disease burden with QALY.
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Affiliation(s)
- Jin Yong Lee
- Public Health Medical Service, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea.,Institute of Health Policy and Management, Medical Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Minsu Ock
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Min-Woo Jo
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Woo-Seung Son
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyeon-Jeong Lee
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seon-Ha Kim
- Department of Nursing, College of Nursing, Dankook University, Cheonan, Republic of Korea
| | - Hyun Joo Kim
- Department of Nursing Science, Shinsung University, Dangjin, Republic of Korea
| | - Jong Lyul Lee
- Departments of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Combining patient preferences with expected treatment outcomes to inform decision-making. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2017. [DOI: 10.1007/s10742-016-0166-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Aronsson M, Carlsson P, Levin LÅ, Hager J, Hultcrantz R. Cost-effectiveness of high-sensitivity faecal immunochemical test and colonoscopy screening for colorectal cancer. Br J Surg 2017; 104:1078-1086. [PMID: 28561259 DOI: 10.1002/bjs.10536] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/25/2016] [Accepted: 02/08/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Colorectal cancer screening can decrease morbidity and mortality. However, there are widespread differences in the implementation of programmes and choice of strategy. The primary objective of this study was to estimate lifelong costs and health outcomes of two of the currently most preferred methods of screening for colorectal cancer: colonoscopy and sensitive faecal immunochemical test (FIT). METHODS A cost-effectiveness analysis of colorectal cancer screening in a Swedish population was performed using a decision analysis model, based on the design of the Screening of Swedish Colons (SCREESCO) study, and data from the published literature and registries. Lifelong cost and effects of colonoscopy once, colonoscopy every 10 years, FIT twice, FIT biennially and no screening were estimated using simulations. RESULTS For 1000 individuals invited to screening, it was estimated that screening once with colonoscopy yielded 49 more quality-adjusted life-years (QALYs) and a cost saving of €64 800 compared with no screening. Similarly, screening twice with FIT gave 26 more QALYs and a cost saving of €17 600. When the colonoscopic screening was repeated every tenth year, 7 additional QALYs were gained at a cost of €189 400 compared with a single colonoscopy. The additional gain with biennial FIT screening was 25 QALYs at a cost of €154 300 compared with two FITs. CONCLUSION All screening strategies were cost-effective compared with no screening. Repeated and single screening strategies with colonoscopy were more cost-effective than FIT when lifelong effects and costs were considered. However, other factors such as patient acceptability of the test and availability of human resources also have to be taken into account.
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Affiliation(s)
- M Aronsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - P Carlsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - L-Å Levin
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - J Hager
- Departments of Surgery and Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden
| | - R Hultcrantz
- Department of Gastroenterology and Hepatology, Karolinska Institute, Karolinska University Hospital, Solna, Sweden
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Meulen MPVD, Kapidzic A, Leerdam MEV, van der Steen A, Kuipers EJ, Spaander MCW, de Koning HJ, Hol L, Lansdorp-Vogelaar I. Do Men and Women Need to Be Screened Differently with Fecal Immunochemical Testing? A Cost-Effectiveness Analysis. Cancer Epidemiol Biomarkers Prev 2017; 26:1328-1336. [PMID: 28515110 DOI: 10.1158/1055-9965.epi-16-0786] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 02/24/2017] [Accepted: 05/04/2017] [Indexed: 11/16/2022] Open
Abstract
Background: Several studies suggest that test characteristics for the fecal immunochemical test (FIT) differ by gender, triggering a debate on whether men and women should be screened differently. We used the microsimulation model MISCAN-Colon to evaluate whether screening stratified by gender is cost-effective.Methods: We estimated gender-specific FIT characteristics based on first-round positivity and detection rates observed in a FIT screening pilot (CORERO-1). Subsequently, we used the model to estimate harms, benefits, and costs of 480 gender-specific FIT screening strategies and compared them with uniform screening.Results: Biennial FIT screening from ages 50 to 75 was less effective in women than men [35.7 vs. 49.0 quality-adjusted life years (QALY) gained, respectively] at higher costs (€42,161 vs. -€5,471, respectively). However, the incremental QALYs gained and costs of annual screening compared with biennial screening were more similar for both genders (8.7 QALYs gained and €26,394 for women vs. 6.7 QALYs gained and €20,863 for men). Considering all evaluated screening strategies, optimal gender-based screening yielded at most 7% more QALYs gained than optimal uniform screening and even resulted in equal costs and QALYs gained from a willingness-to-pay threshold of €1,300.Conclusions: FIT screening is less effective in women, but the incremental cost-effectiveness is similar in men and women. Consequently, screening stratified by gender is not more cost-effective than uniform FIT screening.Impact: Our conclusions support the current policy of uniform FIT screening. Cancer Epidemiol Biomarkers Prev; 26(8); 1328-36. ©2017 AACR.
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Affiliation(s)
| | - Atija Kapidzic
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Monique E van Leerdam
- Department of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Alex van der Steen
- Department of Public Health, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands.,Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
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Adding bevacizumab to single agent chemotherapy for the treatment of platinum-resistant recurrent ovarian cancer: A cost effectiveness analysis of the AURELIA trial. Gynecol Oncol 2017; 145:340-345. [PMID: 28291545 DOI: 10.1016/j.ygyno.2017.02.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/21/2017] [Accepted: 02/24/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE AURELIA, a randomized phase III trial of adding bevacizumab (B) to single agent chemotherapy (CT) for the treatment of platinum-resistant recurrent ovarian cancer, demonstrated improved progression free survival (PFS) in the B+CT arm compared to CT alone. We aimed to evaluate the cost effectiveness of adding B to CT in the treatment of platinum-resistant recurrent ovarian cancer. METHODS A decision tree model was constructed to evaluate the cost effectiveness of adding bevacizumab (B) to single agent chemotherapy (CT) based on the arms of the AURELIA trial. Costs, quality-adjusted life years (QALYs), and progression free survival (PFS) were modeled over fifteen months. Model inputs were extracted from published literature and public sources. Incremental cost effectiveness ratios (ICERs) per QALY gained and ICERs per progression free life year saved (PF-LYS) were calculated. One-way sensitivity analyses were performed to evaluate the robustness of results. RESULTS The ICER associated with B+CT is $410,455 per QALY gained and $217,080 per PF-LYS. At a willingness to pay (WTP) threshold of $50,000/QALY, adding B to single agent CT is not cost effective for this patient population. Even at a WTP threshold of $100,000/QALY, B+CT is not cost effective. These findings are robust to sensitivity analyses. CONCLUSIONS Despite gains in QALY and PFS, the addition of B to single agent CT for treatment of platinum-resistant recurrent ovarian cancer is not cost effective. Benefits, risks, and costs associated with treatment should be taken into consideration when prescribing chemotherapy for this patient population.
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Yachimski P, Hur C. Endoscopic therapy versus surgery for T1 colon cancer: defining model clinical practice. Gastrointest Endosc 2016; 84:995-996. [PMID: 27855802 PMCID: PMC6738565 DOI: 10.1016/j.gie.2016.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/30/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Patrick Yachimski
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chin Hur
- Institute for Technology Assessment and Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Currie AC, Askari A, Rao C, Saunders BP, Athanasiou T, Faiz OD, Kennedy RH. The potential impact of local excision for T1 colonic cancer in elderly and comorbid populations: a decision analysis. Gastrointest Endosc 2016; 84:986-994. [PMID: 27189656 DOI: 10.1016/j.gie.2016.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 05/09/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Population-based bowel cancer screening has resulted in increasing numbers of patients with T1 colonic cancer. The need for colectomy in this group is questioned due to the low risk of lymphatic spread and increased treatment morbidity, particularly for elderly, comorbid patients. This study examined the quality-of-life benefits and risks of endoscopic resection compared with results after colectomy, for low-risk and high-risk T1 colonic cancer. METHODS Decision analysis using a Markov simulation model was performed; patients were managed with either endoscopic resection (advanced therapeutic endoscopy) or colectomy. Lesions were considered high risk according to accepted national guidelines. Probabilities and utilities (perception of quality of life) were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients with low-risk or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs). RESULTS In low-risk T1 colonic neoplasia, endoscopic resection increases QALE by 0.09 QALYS for fit 65-year-olds and by 0.67 for unfit 80-year-olds. For high-risk T1 cancers, the QALE benefit for surgical resection is 0.24 QALYs for fit 65-year-olds and the endoscopic QALE benefit is 0.47 for unfit 80-year-olds. The model findings only favored surgery with high local recurrence rates and when quality of life under surveillance was perceived poorly. CONCLUSIONS Under broad assumptions, endoscopic resection is a reasonable treatment option for both low-risk and high-risk T1 colonic cancer, particularly in elderly, comorbid patients. Exploration of methods to facilitate endoscopic resection of T1 colonic neoplasia appears warranted.
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Affiliation(s)
- Andrew C Currie
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK
| | - Alan Askari
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK
| | - Christopher Rao
- Department of Surgery, Queen Elizabeth Hospital, Woolwich, London, UK
| | - Brian P Saunders
- Wolfson Department of Endoscopy, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Omar D Faiz
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK
| | - Robin H Kennedy
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK
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Jeong K, Cairns J. Systematic review of health state utility values for economic evaluation of colorectal cancer. HEALTH ECONOMICS REVIEW 2016; 6:36. [PMID: 27541298 PMCID: PMC4991979 DOI: 10.1186/s13561-016-0115-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 08/12/2016] [Indexed: 05/30/2023]
Abstract
Cost-utility analyses undertaken to inform decision making regarding colorectal cancer (CRC) require a set of health state utility values (HSUVs) so that the time CRC patients spend in different health states can be aggregated into quality-adjusted life-years (QALY). This study reviews CRC-related HSUVs that could be used in economic evaluation and assesses their advantages and disadvantages with respect to valuation methods used and CRC clinical pathways. Fifty-seven potentially relevant studies were identified which collectively report 321 CRC-related HSUVs. HSUVs (even for similar health states) vary markedly and this adds to the uncertainty regarding estimates of cost-effectiveness. There are relatively few methodologically robust HSUVs that can be directly used in economic evaluations concerned with CRC. There is considerable scope to develop new HSUVs which improve on those currently available either by expanded collection of generic measures or by making greater use of condition-specific data, for example, using mapping algorithms.
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Affiliation(s)
- Kim Jeong
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - John Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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Kisiel JB, Konijeti GG, Piscitello AJ, Chandra T, Goss TF, Ahlquist DA, Farraye FA, Ananthakrishnan AN. Stool DNA Analysis is Cost-Effective for Colorectal Cancer Surveillance in Patients With Ulcerative Colitis. Clin Gastroenterol Hepatol 2016; 14:1778-1787.e8. [PMID: 27464589 PMCID: PMC5108686 DOI: 10.1016/j.cgh.2016.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/17/2016] [Accepted: 07/10/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with chronic ulcerative colitis are at increased risk for colorectal neoplasia (CRN). Surveillance by white-light endoscopy (WLE) or chromoendoscopy may reduce risk of CRN, but these strategies are underused. Analysis of DNA from stool samples (sDNA) can detect CRN with high levels of sensitivity, but it is not clear if this approach is cost-effective. We simulated these strategies for CRN detection to determine which approach is most cost-effective. METHODS We adapted a previously published Markov model to simulate the clinical course of chronic ulcerative colitis, the incidence of cancer or dysplasia, and costs and benefits of care with 4 surveillance strategies: (1) analysis of sDNA and diagnostic chromoendoscopy for patients with positive results, (2) analysis of sDNA with diagnostic WLE for patients with positive results, (3) chromoendoscopy with targeted collection of biopsies, or (4) WLE with random collection of biopsies. Costs were based on 2014 Medicare reimbursement. The primary outcome was the incremental cost-effectiveness ratio (incremental cost/incremental difference in quality-adjusted life-years) compared with no surveillance and a willingness-to-pay threshold of $50,000. RESULTS All strategies fell below the willingness-to-pay threshold at 2-year intervals. Incremental cost-effectiveness ratios were $16,362 per quality-adjusted life-year for sDNA analysis with diagnostic chromoendoscopy; $18,643 per quality-adjusted life-year for sDNA analysis with diagnostic WLE; $23,830 per quality-adjusted life-year for chromoendoscopy alone; and $27,907 per quality-adjusted life-year for WLE alone. In sensitivity analyses, sDNA analysis with diagnostic chromoendoscopy was more cost-effective than chromoendoscopy alone, up to a cost of $1135 per sDNA test. sDNA analysis remained cost-effective at all rates of compliance; when combined with diagnostic chromoendoscopy, this approach was preferred over chromoendoscopy alone, when the specificity of the sDNA test for CRN was >65%. CONCLUSIONS Based on a Markov model, surveillance for CRN is cost-effective for patients with chronic ulcerative colitis. Analysis of sDNA with chromoendoscopies for patients with positive results was more cost-effective than chromoendoscopy or WLE alone.
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Affiliation(s)
- John B. Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester MN
| | - Gauree G. Konijeti
- Division of Gastroenterology, Scripps Clinic, La Jolla CA,Scripps Translational Science Institute, La Jolla, CA
| | | | | | | | - David A. Ahlquist
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester MN
| | - Francis A. Farraye
- Center for Digestive Disorders, Boston Medical Center, Section of Gastroenterology, Boston University School of Medicine, Boston MA
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital and Harvard Medical School, Boston MA
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Taksler GB, Perzynski AT, Kattan MW. Modeling Individual Patient Preferences for Colorectal Cancer Screening Based on Their Tolerance for Complications Risk. Med Decis Making 2016; 37:204-215. [PMID: 27879412 DOI: 10.1177/0272989x16679161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Recommendations for colorectal cancer screening encourage patients to choose among various screening methods based on individual preferences for benefits, risks, screening frequency, and discomfort. We devised a model to illustrate how individuals with varying tolerance for screening complications risk might decide on their preferred screening strategy. METHODS We developed a discrete-time Markov mathematical model that allowed hypothetical individuals to maximize expected lifetime utility by selecting screening method, start age, stop age, and frequency. Individuals could choose from stool-based testing every 1 to 3 years, flexible sigmoidoscopy every 1 to 20 years with annual stool-based testing, colonoscopy every 1 to 20 years, or no screening. We compared the life expectancy gained from the chosen strategy with the life expectancy available from a benchmark strategy of decennial colonoscopy. RESULTS For an individual at average risk of colorectal cancer who was risk neutral with respect to screening complications (and therefore was willing to undergo screening if it would actuarially increase life expectancy), the model predicted that he or she would choose colonoscopy every 10 years, from age 53 to 73 years, consistent with national guidelines. For a similar individual who was moderately averse to screening complications risk (and therefore required a greater increase in life expectancy to accept potential risks of colonoscopy), the model predicted that he or she would prefer flexible sigmoidoscopy every 12 years with annual stool-based testing, with 93% of the life expectancy benefit of decennial colonoscopy. For an individual with higher risk aversion, the model predicted that he or she would prefer 2 lifetime flexible sigmoidoscopies, 20 years apart, with 70% of the life expectancy benefit of decennial colonoscopy. CONCLUSION Mathematical models may formalize how individuals with different risk attitudes choose between various guideline-recommended colorectal cancer screening strategies.
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Affiliation(s)
- Glen B Taksler
- Medicine Institute, Cleveland Clinic, Cleveland, OH (GBT)
| | - Adam T Perzynski
- Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth Medical Center, Cleveland, OH (ATP)
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK)
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Interval Appendectomy: Finding the Breaking Point for Cost-Effectiveness. J Am Coll Surg 2016; 223:632-43. [PMID: 27502367 DOI: 10.1016/j.jamcollsurg.2016.07.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 12/29/2022]
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Freeman K, Connock M, Cummins E, Gurung T, Taylor-Phillips S, Court R, Saunders M, Clarke A, Sutcliffe P. Fluorouracil plasma monitoring: systematic review and economic evaluation of the My5-FU assay for guiding dose adjustment in patients receiving fluorouracil chemotherapy by continuous infusion. Health Technol Assess 2016; 19:1-321, v-vi. [PMID: 26542268 DOI: 10.3310/hta19910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND 5-Fluorouracil (5-FU) is a chemotherapy used in colorectal, head and neck (H&N) and other cancers. Dose adjustment is based on body surface area (BSA) but wide variations occur. Pharmacokinetic (PK) dosing is suggested to bring plasma levels into the therapeutic range to promote fewer side effects and better patient outcomes. We investigated the clinical effectiveness and cost-effectiveness of the My5-FU assay for PK dose adjustment to 5-FU therapy. OBJECTIVES To systematically review the evidence on the accuracy of the My5-FU assay compared with gold standard methods [high-performance liquid chromatography (HPLC) and liquid chromatography-mass spectrometry (LC-MS)]; the effectiveness of My5-FU PK dosing compared with BSA; the effectiveness of HPLC and/or LC-MS compared with BSA; the generalisability of published My5-FU and PK studies; costs of using My5-FU; to develop a cost-effectiveness model. DATA SOURCES We searched MEDLINE, EMBASE, Science Citation Index and other databases between January and April 2014. METHODS Two reviewers independently screened titles and abstracts with arbitration and consensus agreement. We undertook quality assessment. We reconstructed Kaplan-Meier plots for progression-free survival (PFS) and overall survival (OS) for comparison of BSA and PK dosing. We developed a Markov model to compare My5-FU with BSA dosing which modelled PFS, OS and adverse events, using a 2-week cycle over a 20 year time horizon with a 3.5% discount rate. Health impacts were evaluated from the patient perspective, while costs were evaluated from the NHS and Personal Social Services perspective. RESULTS A total of 8341 records were identified through electronic searches and 35 and 54 studies were included in the clinical effectiveness and cost-effectiveness reviews respectively. There was a high apparent correlation between My5-FU, HPLC and LC-MS/mass spectrometer but upper and lower limits of agreement were -18% to 30%. Median OS were estimated as 19.6 [95% confidence interval (CI) 17.0 to 21.0] months for PK versus 14.6 (95% CI 14.1 to 15.3) months for BSA for 5-FU+folinic acid (FA); and 27.4 (95% CI 23.2 to 38.8) months for PK versus 20.6 (95% CI 18.4 to 22.9) months for BSA for FOLFOX6 in metastatic colorectal cancer (mCRC). PK versus BSA studies were generalisable to the relevant populations. We developed cost-effectiveness models for mCRC and H&N cancer. The base case assumed a cost per My5-FU assay of £ 61.03. For mCRC for 12 cycles of a oxaliplatin in combination with 5-fluorouracil and FA (FOLFOX) regimen, there was a quality-adjusted life-year (QALY) gain of 0.599 with an incremental cost-effectiveness ratio of £ 4148 per QALY. Probabilistic and scenario analyses gave similar results. The cost-effectiveness acceptability curve showed My5-FU to be 100% cost-effective at a threshold of £ 20,000 per QALY. For H&N cancer, again, given caveats about the poor evidence base, we also estimated that My5-FU is likely to be cost-effective at a threshold of £ 20,000 per QALY. LIMITATIONS Quality and quantity of evidence were very weak for PK versus BSA dosing for all cancers with no randomised controlled trials (RCTs) using current regimens. For H&N cancer, two studies of regimens no longer in use were identified. CONCLUSIONS Using a linked evidence approach, My5-FU appears to be cost-effective at a willingness to pay of £ 20,000 per QALY for both mCRC and H&N cancer. Considerable uncertainties remain about evidence quality and practical implementation. RCTs are needed of PK versus BSA dosing in relevant cancers.
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Affiliation(s)
| | - Martin Connock
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Tara Gurung
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mark Saunders
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
| | - Aileen Clarke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Sutcliffe
- Warwick Medical School, University of Warwick, Coventry, UK
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Knudsen AB, Zauber AG, Rutter CM, Naber SK, Doria-Rose VP, Pabiniak C, Johanson C, Fischer SE, Lansdorp-Vogelaar I, Kuntz KM. Estimation of Benefits, Burden, and Harms of Colorectal Cancer Screening Strategies: Modeling Study for the US Preventive Services Task Force. JAMA 2016; 315:2595-609. [PMID: 27305518 PMCID: PMC5493310 DOI: 10.1001/jama.2016.6828] [Citation(s) in RCA: 331] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The US Preventive Services Task Force (USPSTF) is updating its 2008 colorectal cancer (CRC) screening recommendations. OBJECTIVE To inform the USPSTF by modeling the benefits, burden, and harms of CRC screening strategies; estimating the optimal ages to begin and end screening; and identifying a set of model-recommendable strategies that provide similar life-years gained (LYG) and a comparable balance between LYG and screening burden. DESIGN, SETTING, AND PARTICIPANTS Comparative modeling with 3 microsimulation models of a hypothetical cohort of previously unscreened US 40-year-olds with no prior CRC diagnosis. EXPOSURES Screening with sensitive guaiac-based fecal occult blood testing, fecal immunochemical testing (FIT), multitarget stool DNA testing, flexible sigmoidoscopy with or without stool testing, computed tomographic colonography (CTC), or colonoscopy starting at age 45, 50, or 55 years and ending at age 75, 80, or 85 years. Screening intervals varied by modality. Full adherence for all strategies was assumed. MAIN OUTCOMES AND MEASURES Life-years gained compared with no screening (benefit), lifetime number of colonoscopies required (burden), lifetime number of colonoscopy complications (harms), and ratios of incremental burden and benefit (efficiency ratios) per 1000 40-year-olds. RESULTS The screening strategies provided LYG in the range of 152 to 313 per 1000 40-year-olds. Lifetime colonoscopy burden per 1000 persons ranged from fewer than 900 (FIT every 3 years from ages 55-75 years) to more than 7500 (colonoscopy screening every 5 years from ages 45-85 years). Harm from screening was at most 23 complications per 1000 persons screened. Strategies with screening beginning at age 50 years generally provided more LYG as well as more additional LYG per additional colonoscopy than strategies with screening beginning at age 55 years. There were limited empirical data to support a start age of 45 years. For persons adequately screened up to age 75 years, additional screening yielded small increases in LYG relative to the increase in colonoscopy burden. With screening from ages 50 to 75 years, 4 strategies yielded a comparable balance of screening burden and similar LYG (median LYG per 1000 across the models): colonoscopy every 10 years (270 LYG); sigmoidoscopy every 10 years with annual FIT (256 LYG); CTC every 5 years (248 LYG); and annual FIT (244 LYG). CONCLUSIONS AND RELEVANCE In this microsimulation modeling study of a previously unscreened population undergoing CRC screening that assumed 100% adherence, the strategies of colonoscopy every 10 years, annual FIT, sigmoidoscopy every 10 years with annual FIT, and CTC every 5 years performed from ages 50 through 75 years provided similar LYG and a comparable balance of benefit and screening burden.
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Affiliation(s)
- Amy B Knudsen
- Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Steffie K Naber
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | | | - Colden Johanson
- Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts8Currently with Optum, Boston, Massachusetts
| | - Sara E Fischer
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Karen M Kuntz
- Department of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
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Fu AZ, Graves KD, Jensen RE, Marshall JL, Formoso M, Potosky AL. Patient preference and decision-making for initiating metastatic colorectal cancer medical treatment. J Cancer Res Clin Oncol 2016; 142:699-706. [PMID: 26577827 PMCID: PMC4752940 DOI: 10.1007/s00432-015-2073-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Some medical treatment for metastatic colorectal cancer (CRC) may have marginal survival benefit, but cause toxicities. The purpose of this study is to determine metastatic CRC patients' tradeoffs in making a decision to undergo new medical treatment. METHODS We conducted a survey of patients with a diagnosis of advanced CRC who were currently receiving or completed one chemotherapy regimen. First, patients were asked to rate the importance of 15 medical treatment-related adverse events that may arise as a consequence of chemotherapy or biological therapy in their treatment decision-making. Then, the patient identified his or her top five most important events and solicited preferences in hypothetical metastatic CRC treatment vignettes using the standard gamble technique. RESULTS A total of 107 patients responded to the survey. From the list of medical treatment-related adverse events, patients identified clinically serious ones such as stroke, heart attack, and gastrointestinal perforation as the most important in their medical treatment decision-making, yet placed lower willingness to tolerate symptom-related events such as pain, fatigue, and depression. Generally, patients who were older, stage III versus IV and who had prior radiotherapy, lower educational attainment, and lower household income (all p <0.05) were less willing to tolerate any medical treatment-related adverse events after adjusting for other demographic and clinical characteristics. CONCLUSIONS Variations in patients' willingness to tolerate different treatment-related adverse events underscore the need for improved communications between physicians and patients about the risks and benefits of their medical treatment, which helps make a more personalized decision for metastatic CRC treatment.
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Affiliation(s)
- Alex Z Fu
- Department of Oncology, Georgetown University, Washington, DC, USA.
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA.
| | - Kristi D Graves
- Department of Oncology, Georgetown University, Washington, DC, USA
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Roxanne E Jensen
- Department of Oncology, Georgetown University, Washington, DC, USA
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - John L Marshall
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Margaret Formoso
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Arnold L Potosky
- Department of Oncology, Georgetown University, Washington, DC, USA
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
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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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Soni A, Chu E. Cost-Effectiveness of Adjuvant Chemotherapy in the Treatment of Early-Stage Colon Cancer. Clin Colorectal Cancer 2015; 14:219-26. [DOI: 10.1016/j.clcc.2015.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/10/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
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van Hees F, Saini SD, Lansdorp-Vogelaar I, Vijan S, Meester RGS, de Koning HJ, Zauber AG, van Ballegooijen M. Personalizing colonoscopy screening for elderly individuals based on screening history, cancer risk, and comorbidity status could increase cost effectiveness. Gastroenterology 2015; 149:1425-37. [PMID: 26253304 PMCID: PMC4631390 DOI: 10.1053/j.gastro.2015.07.042] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) screening decisions for elderly individuals are often made primarily on the basis of age, whereas other factors that influence the effectiveness and cost effectiveness of screening are often not considered. We investigated the relative importance of factors that could be used to identify elderly individuals most likely to benefit from CRC screening and determined the maximum ages at which screening remains cost effective based on these factors. METHODS We used a microsimulation model (Microsimulation Screening Analysis-Colon) calibrated to the incidence of CRC in the United States and the prevalence of adenomas reported in autopsy studies to determine the appropriate age at which to stop colonoscopy screening in 19,200 cohorts (of 10 million individuals), defined by sex, race, screening history, background risk for CRC, and comorbidity status. We applied a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY) gained. RESULTS Less intensive screening history, higher background risk for CRC, and fewer comorbidities were associated with cost-effective screening at older ages. Sex and race had only a small effect on the appropriate age to stop screening. For some individuals likely to be screened in current practice (for example, 74-year-old white women with moderate comorbidities, half the average background risk for CRC, and negative findings from a screening colonoscopy 10 years previously), screening resulted in a loss of QALYs, rather than a gain. For some individuals unlikely to be screened in current practice (for example, 81-year-old black men with no comorbidities, an average background risk for CRC, and no previous screening), screening was highly cost effective. Although screening some previously screened, low-risk individuals was not cost effective even when they were 66 years old, screening some healthy, high-risk individuals remained cost effective until they reached the age of 88 years old. CONCLUSIONS The current approach to CRC screening in elderly individuals, in which decisions are often based primarily on age, is inefficient, resulting in underuse of screening for some and overuse of screening for others. CRC screening could be more effective and cost effective if individual factors for each patient are considered.
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Affiliation(s)
- Frank van Hees
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sameer D Saini
- Veteran Affairs Health Services Research and Development Center for Clinical Management Research, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sandeep Vijan
- Veteran Affairs Health Services Research and Development Center for Clinical Management Research, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Reinier G S Meester
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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Wong CKH, Lam CLK, Wan YF, Fong DYT. Cost-effectiveness simulation and analysis of colorectal cancer screening in Hong Kong Chinese population: comparison amongst colonoscopy, guaiac and immunologic fecal occult blood testing. BMC Cancer 2015; 15:705. [PMID: 26471036 PMCID: PMC4608156 DOI: 10.1186/s12885-015-1730-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 10/08/2015] [Indexed: 12/19/2022] Open
Abstract
Background The aim of this study was to evaluate the cost-effectiveness of CRC screening strategies from the healthcare service provider perspective based on Chinese population. Methods A Markov model was constructed to compare the cost-effectiveness of recommended screening strategies including annual/biennial guaiac fecal occult blood testing (G-FOBT), annual/biennial immunologic FOBT (I-FOBT), and colonoscopy every 10 years in Chinese aged 50 year over a 25-year period. External validity of model was tested against data retrieved from published randomized controlled trials of G-FOBT. Recourse use data collected from Chinese subjects among staging of colorectal neoplasm were combined with published unit cost data ($USD in 2009 price values) to estimate a stage-specific cost per patient. Quality-adjusted life-years (QALYs) were quantified based on the stage duration and SF-6D preference-based value of each stage. The cost-effectiveness outcome was the incremental cost-effectiveness ratio (ICER) represented by costs per life-years (LY) and costs per QALYs gained. Results In base-case scenario, the non-dominated strategies were annual and biennial I-FOBT. Compared with no screening, the ICER presented $20,542/LYs and $3155/QALYs gained for annual I-FOBT, and $19,838/LYs gained and $2976/QALYs gained for biennial I-FOBT. The optimal screening strategy was annual I-FOBT that attained the highest ICER at the threshold of $50,000 per LYs or QALYs gained. Conclusion The Markov model informed the health policymakers that I-FOBT every year may be the most effective and cost-effective CRC screening strategy among recommended screening strategies, depending on the willingness-to-pay of mass screening for Chinese population. Trial registration ClinicalTrials.gov Identifier NCT02038283 Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1730-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carlos K H Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong, Hong Kong.
| | - Cindy L K Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong, Hong Kong
| | - Y F Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong, Hong Kong
| | - Daniel Y T Fong
- School of Nursing, The University of Hong Kong, Hong Kong, Hong Kong
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Snowsill T, Huxley N, Hoyle M, Jones-Hughes T, Coelho H, Cooper C, Frayling I, Hyde C. A systematic review and economic evaluation of diagnostic strategies for Lynch syndrome. Health Technol Assess 2015; 18:1-406. [PMID: 25244061 DOI: 10.3310/hta18580] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lynch syndrome (LS) is an inherited autosomal dominant disorder characterised by an increased risk of colorectal cancer (CRC) and other cancers, and caused by mutations in the deoxyribonucleic acid (DNA) mismatch repair genes. OBJECTIVE To evaluate the accuracy and cost-effectiveness of strategies to identify LS in newly diagnosed early-onset CRC patients (aged < 50 years). Cascade testing of relatives is employed in all strategies for individuals in whom LS is identified. DATA SOURCES AND METHODS Systematic reviews were conducted of the test accuracy of microsatellite instability (MSI) testing or immunohistochemistry (IHC) in individuals with CRC at risk of LS, and of economic evidence relating to diagnostic strategies for LS. Reviews were carried out in April 2012 (test accuracy); and in February 2012, repeated in February 2013 (economic evaluations). Databases searched included MEDLINE (1946 to April week 3, 2012), EMBASE (1980 to week 17, 2012) and Web of Science (inception to 30 April 2012), and risk of bias for test accuracy was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) quality appraisal tool. A de novo economic model of diagnostic strategies for LS was developed. RESULTS Inconsistencies in study designs precluded pooling of diagnostic test accuracy results from a previous systematic review and nine subsequent primary studies. These were of mixed quality, with significant methodological concerns identified for most. IHC and MSI can both play a part in diagnosing LS but neither is gold standard. No UK studies evaluated the cost-effectiveness of diagnosing and managing LS, although studies from other countries generally found some strategies to be cost-effective compared with no testing. The de novo model demonstrated that all strategies were cost-effective compared with no testing at a threshold of £20,000 per quality-adjusted life-year (QALY), with the most cost-effective strategy utilising MSI and BRAF testing [incremental cost-effectiveness ratio (ICER) = £5491 per QALY]. The maximum health benefit to the population of interest would be obtained using universal germline testing, but this would not be a cost-effective use of NHS resources compared with the next best strategy. When the age limit was raised from 50 to 60 and 70 years, the ICERs compared with no testing increased but remained below £20,000 per QALY (except for universal germline testing with an age limit of 70 years). The total net health benefit increased with the age limit as more individuals with LS were identified. Uncertainty was evaluated through univariate sensitivity analyses, which suggested that the parameters substantially affecting cost-effectiveness: were the risk of CRC for individuals with LS; the average number of relatives identified per index patient; the effectiveness of colonoscopy in preventing metachronous CRC; the cost of colonoscopy; the duration of the psychological impact of genetic testing on health-related quality of life (HRQoL); and the impact of prophylactic hysterectomy and bilateral salpingo-oophorectomy on HRQoL (this had the potential to make all testing strategies more expensive and less effective than no testing). LIMITATIONS The absence of high-quality data for the impact of prophylactic gynaecological surgery and the psychological impact of genetic testing on HRQoL is an acknowledged limitation. CONCLUSIONS Results suggest that reflex testing for LS in newly diagnosed CRC patients aged < 50 years is cost-effective. Such testing may also be cost-effective in newly diagnosed CRC patients aged < 60 or < 70 years. Results are subject to uncertainty due to a number of parameters, for some of which good estimates were not identified. We recommend future research to estimate the cost-effectiveness of testing for LS in individuals with newly diagnosed endometrial or ovarian cancer, and the inclusion of aspirin chemoprevention. Further research is required to accurately estimate the impact of interventions on HRQoL. STUDY REGISTRATION This study is registered as PROSPERO CRD42012002436. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Ian Frayling
- Institute of Medical Genetics, Cardiff University, Cardiff, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
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Wilson FA, Villarreal R, Stimpson JP, Pagán JA. Cost-effectiveness analysis of a colonoscopy screening navigator program designed for Hispanic men. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2015; 30:260-267. [PMID: 25168070 DOI: 10.1007/s13187-014-0718-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Although Hispanic men are at higher risk of developing colon cancer compared to non-Hispanic white men, colonoscopy screening among Hispanic men is much lower than among non-Hispanic white men. University Health System (UHS) in San Antonio, Texas, instituted a Colorectal Cancer Male Navigation (CCMN) Program in 2011 specifically designed for Hispanic men. The CCMN Program contacted 461 Hispanic men 50 years of age and older to participate over a 2-year period. Of these age-eligible men, 370 were screened for CRC after being contacted by the navigator. Using participant and program data, a Markov model was constructed to determine the cost-effectiveness of the CCMN Program. An average 50-year-old Hispanic male who participates in the CCMN Program will have 0.3 more quality-adjusted life-years (QALYs) compared to a similar male receiving usual care. Life expectancy is also predicted to increase by 6 months for participants compared to non-participants. The program results in net health care savings of $1,148 per participant ($424,760 for the 370 CCMN Program participants). The incremental cost-effectiveness ratio is estimated at $3,765 per QALY in favor of the navigation program. Interventions to reduce disparities in CRC screening across ethnic groups are needed, and this is one of the first studies to evaluate the economic benefit of a patient navigator program specifically designed for an urban population of Hispanic men. A colorectal cancer screening intervention which relies on patient navigators trained to address the unique needs of the targeted population (language barriers, transportation and scheduling assistance, colon cancer, and screening knowledge) can substantially increase the likelihood of screening and improve quality of life in a cost-effective manner.
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Affiliation(s)
- Fernando A Wilson
- Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, 68198, NE, USA
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Colorectal cancer surveillance in patients with inflammatory bowel disease and primary sclerosing cholangitis: an economic evaluation. Inflamm Bowel Dis 2014; 20:2046-55. [PMID: 25230162 DOI: 10.1097/mib.0000000000000181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The cost-effectiveness of annual colonoscopy for detection of colorectal neoplasia among patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) is uncertain. The aim of this study was to determine whether annual colonoscopy among patients with IBD-PSC is cost-effective compared with less frequent intervals from the perspective of a publicly funded health care system. METHODS A cost-utility analysis using a Markov model was used to simulate a 35-year-old patient with a 10-year history of well-controlled IBD and a recent diagnosis of concomitant PSC. The following strategies were compared: no surveillance, colonoscopy every 5 years, biennial colonoscopy, and annual colonoscopy. Outcome measures included: costs, number of cases of dysplasia found, number of cancers found and missed, deaths, quality-adjusted life-years (QALYs) gained, and the incremental cost per QALY gained. RESULTS In the base-case analysis, no surveillance was the least expensive and least effective strategy. Compared with no surveillance, the cost per QALY of surveillance every 5 years was CAD $15,021. The cost per QALY of biennial surveillance compared with surveillance every 5 years was CAD $37,522. Annual surveillance was more effective than biennial surveillance, but at an incremental cost of CAD $174,650 per QALY gained compared with biennial surveillance. CONCLUSIONS More frequent colonoscopy screening intervals improve effectiveness (i.e., detects more cancers and prevents additional deaths), but at higher cost. Health systems must consider the opportunity costs associated with different surveillance colonoscopy intervals when deciding which strategy to implement among patients with IBD-PSC.
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van Hees F, Zauber AG, Klabunde CN, Goede SL, Lansdorp-Vogelaar I, van Ballegooijen M. The appropriateness of more intensive colonoscopy screening than recommended in Medicare beneficiaries: a modeling study. JAMA Intern Med 2014; 174:1568-76. [PMID: 25133641 PMCID: PMC4416697 DOI: 10.1001/jamainternmed.2014.3889] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Many Medicare beneficiaries undergo more intensive colonoscopy screening than recommended. Whether this is favorable for beneficiaries and efficient from a societal perspective is uncertain. OBJECTIVE To determine whether more intensive colonoscopy screening than recommended is favorable for Medicare beneficiaries (ie, whether it results in a net health benefit) and whether it is efficient from a societal perspective (ie, whether the net health benefit justifies the additional resources required). DESIGN, SETTING, AND PARTICIPANTS Microsimulation modeling study of 65-year-old Medicare beneficiaries at average risk for colorectal cancer (CRC) and with an average life expectancy who underwent a screening colonoscopy at 55 years with negative results. INTERVENTIONS Colonoscopy screening as recommended by guidelines (ie, at 65 and 75 years) vs scenarios with a shorter screening interval (5 or 3 instead of 10 years) or in which screening was continued to 85 or 95 years. MAIN OUTCOMES AND MEASURES Quality-adjusted life-years (QALYs) gained (measure of net health benefit); additional colonoscopies required per additional QALY gained and additional costs per additional QALY gained (measures of efficiency). RESULTS Screening previously screened Medicare beneficiaries more intensively than recommended resulted in only small increases in CRC deaths prevented and life-years gained. In comparison, the increases in colonoscopies performed and colonoscopy-related complications experienced were large. As a result, all scenarios of more intensive screening than recommended resulted in a loss of QALYs, rather than a gain (ie, a net harm). The only exception was shortening the screening interval from 10 to 5 years, which resulted in 0.7 QALYs gained per 1000 beneficiaries. However, this scenario was inefficient because it required no less than 909 additional colonoscopies and an additional $711 000 per additional QALY gained. Results in previously unscreened beneficiaries were slightly less unfavorable, but conclusions were identical. CONCLUSIONS AND RELEVANCE Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides evidence and a clear rationale for clinicians and policy makers to actively discourage this practice.
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Affiliation(s)
- Frank van Hees
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Carrie N Klabunde
- Health Services and Economics Branch, Applied Research Program, National Cancer Institute, Bethesda, Maryland
| | - S Luuk Goede
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
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Djalalov S, Rabeneck L, Tomlinson G, Bremner KE, Hilsden R, Hoch JS. A Review and Meta-analysis of Colorectal Cancer Utilities. Med Decis Making 2014; 34:809-18. [PMID: 24903121 DOI: 10.1177/0272989x14536779] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 04/29/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To perform a systematic review of utility weights for colorectal cancer (CRC) health states reported in the scientific literature and to determine the effects of disease factors, patient characteristics, and utility methods on utility values. METHODS We identified 26 articles written in English and published from January 1980 to January 2013, providing 351 unique utilities for CRC health states elicited from 6546 unique respondents. The CRC utility data were analyzed using linear mixed-effects models with CRC type, stage, time to or from initial care, utility measurement instrument, and administration method as independent variables. RESULTS In the base case model, the estimated utility for a patient with stage I to III CRC more than 1 year after surgery, rated using a self-administered time tradeoff instrument, was 0.90. Stage, time to or from initial care, and utility measurement instrument were associated with statistically significant utility differences ranging from -0.19 to 0.02. Utilities for patients with stage IV cancer were 0.19 lower (P < 0.001) than for those with stage I to III cancer. Utilities elicited at more than 1 year after surgery were 0.05 higher than those elicited at 3 months after surgery (P = 0.008). Estimates of differences between utility measurement instruments were sensitive to how repeated scores in the same patient group were treated, and other findings were sensitive to how the disease stage was modeled and method of administration. CONCLUSIONS Variations in reported utilities are associated with factors such as cancer stage, time to or from initial care, and utility measurement instrument. More research is needed to study why apparently similar patients report different quality of life.
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Affiliation(s)
- Sandjar Djalalov
- Centre for Excellence in Economic Analysis Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (SD, JSH),Pharmacoeconomics Research Unit, Cancer Care Ontario, Toronto, ON, Canada (SD, LR, JSH),Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON, Canada (SD, JSH)
| | - Linda Rabeneck
- Institute of Health Policy, Management and Evaluation and Department of Medicine, University of Toronto, Toronto, ON, Canada (LR, GT, JSH),Pharmacoeconomics Research Unit, Cancer Care Ontario, Toronto, ON, Canada (SD, LR, JSH)
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation and Department of Medicine, University of Toronto, Toronto, ON, Canada (LR, GT, JSH),Department of Medicine, University Health Network/Mt. Sinai Hospital, Toronto, ON, Canada (GT)
| | | | | | - Jeffrey S Hoch
- Centre for Excellence in Economic Analysis Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (SD, JSH),Pharmacoeconomics Research Unit, Cancer Care Ontario, Toronto, ON, Canada (SD, LR, JSH),Canadian Centre for Applied Research in Cancer Control (ARCC), Toronto, ON, Canada (SD, JSH)
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van Hees F, Habbema JDF, Meester RG, Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG. Should colorectal cancer screening be considered in elderly persons without previous screening? A cost-effectiveness analysis. Ann Intern Med 2014; 160:750-9. [PMID: 24887616 PMCID: PMC4109030 DOI: 10.7326/m13-2263] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The U.S. Preventive Services Task Force recommends against routine screening for colorectal cancer (CRC) in adequately screened persons older than 75 years but does not address the appropriateness of screening in elderly persons without previous screening. OBJECTIVE To determine at what ages CRC screening should be considered in unscreened elderly persons and to determine which test is indicated at each age. DESIGN Microsimulation modeling study. DATA SOURCES Observational and experimental studies. TARGET POPULATION Unscreened persons aged 76 to 90 years with no, moderate, and severe comorbid conditions. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION One-time colonoscopy, sigmoidoscopy, or fecal immunochemical test (FIT) screening. OUTCOME MEASURES Quality-adjusted life-years gained, costs, and costs per quality-adjusted life-year gained. RESULTS OF BASE-CASE ANALYSIS In unscreened elderly persons with no comorbid conditions, CRC screening was cost-effective up to age 86 years. Screening with colonoscopy was indicated up to age 83 years, sigmoidoscopy was indicated at age 84 years, and FIT was indicated at ages 85 and 86 years. In unscreened persons with moderate comorbid conditions, screening was cost-effective up to age 83 years (colonoscopy indicated up to age 80 years, sigmoidoscopy at age 81 years, and FIT at ages 82 and 83 years). In unscreened persons with severe comorbid conditions, screening was cost-effective up to age 80 years (colonoscopy indicated up to age 77 years, sigmoidoscopy at age 78 years, and FIT at ages 79 and 80 years). RESULTS OF SENSITIVITY ANALYSES Results were most sensitive to assuming a lower willingness to pay per quality-adjusted life-year gained. LIMITATION Only persons at average risk for CRC were considered. CONCLUSION In unscreened elderly persons CRC screening should be considered well beyond age 75 years. A colonoscopy is indicated at most ages. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Frank van Hees
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - J. Dik F. Habbema
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Reinier G. Meester
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iris Lansdorp-Vogelaar
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marjolein van Ballegooijen
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann G. Zauber
- From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York
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81
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Konijeti GG, Shrime MG, Ananthakrishnan AN, Chan AT. Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis. Gastrointest Endosc 2014; 79:455-65. [PMID: 24262637 PMCID: PMC4116277 DOI: 10.1016/j.gie.2013.10.026] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 10/14/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies report that the risk of colorectal cancer (CRC) among patients with ulcerative colitis (UC) may be lower than previously estimated. Although white-light endoscopy (WLE) with random biopsies is recommended for dysplasia detection in patients with UC, several studies reported increased detection of dysplasia by chromoendoscopy. OBJECTIVE To analyze the cost effectiveness of chromoendoscopy relative to WLE or no endoscopy for CRC surveillance in patients with UC. DESIGN Decision-analytic state-transition (Markov) model with Monte Carlo simulation. SETTING To simulate the clinical course of chronic UC, we estimated dysplasia and CRC incidence and progression, endoscopic test characteristics, stage-specific mortality rates, and costs from published literature and Medicare reimbursement data. PATIENTS Patients from a population-based age distribution with ulcerative colitis for ≥8 years. INTERVENTION We compared 3 different strategies at various surveillance intervals: chromoendoscopy with targeted biopsies, WLE with random biopsies, and no surveillance. The robustness of the model was assessed by using probabilistic sensitivity analysis. One-way sensitivity analyses were performed to evaluate individual variables, and 3-dimensional analysis was used to examine the effects of varying screening intervals. MAIN OUTCOME MEASUREMENTS Incremental cost-effectiveness ratio (ICER). RESULTS Chromoendoscopy was found to be more effective and less costly than WLE at all surveillance intervals. However, compared with no surveillance, chromoendoscopy was cost effective only at surveillance intervals of at least 7 years, with an ICER of $77,176. Chromoendoscopy was the most cost effective strategy at sensitivity levels >0.23 for dysplasia detection and cost <$2200, regardless of the level of sensitivity of WLE for dysplasia detection. The estimated population lifetime risk of developing CRC ranged from 2.5% (annual chromoendoscopy) to 5.9% (chromoendoscopy every 10 years). LIMITATIONS Estimates used for the model are based on best available data in the literature. CONCLUSION Chromoendoscopy is both more effective and less costly than WLE and becomes cost effective relative to no surveillance when performed at intervals of ≥7 years.
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Responsiveness was similar between direct and mapped SF-6D in colorectal cancer patients who declined. J Clin Epidemiol 2014; 67:219-27. [DOI: 10.1016/j.jclinepi.2013.08.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/07/2013] [Accepted: 08/12/2013] [Indexed: 02/01/2023]
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Soni A, Aspinall SL, Zhao X, Good CB, Cunningham FE, Chatta G, Passero V, Smith KJ. Cost-Effectiveness Analysis of Adjuvant Stage III Colon Cancer Treatment at Veterans Affairs Medical Centers. Oncol Res 2014; 22:311-9. [PMID: 26629943 PMCID: PMC7842555 DOI: 10.3727/096504015x14424348426152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The objective of this study was to evaluate the real-world cost effectiveness of adjuvant stage III colon cancer chemotherapy regimens, given that previous analyses have been based on data from clinical trials. The study was designed using integrated decision tree and Markov model, which was developed to evaluate the cost effectiveness of 5-fluorouracil/leucovorin (5-FU/LV), capecitabine, and the combination of each with oxaliplatin. The analysis was performed from a US Veterans Affairs perspective via retrospectively collected data, over a 5-year model time horizon. Outcome and cost data were used to calculate cost per quality adjusted life year (QALY), and one-way and probabilistic sensitivity analyses were performed. In the base case analysis, capecitabine and capecitabine plus oxaliplatin both cost more and were less effective than other regimens, and 5-FU/LV plus oxaliplatin, compared to 5-FU/LV alone, resulted in a cost of $25,997 per QALY gained. Model results were generally robust to parameter variation. Capecitabine plus oxaliplatin could be economically reasonable if full dosing occurred ≥76% of the time (base case 42%). In a real-world setting, the addition of oxaliplatin to 5-FU/LV is more effective but also more costly than 5-FU/LV alone. If full dosing of capecitabine-containing regimens can be assured, they may also be cost-effective strategies.
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Affiliation(s)
- Amy Soni
- *University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - Sherrie L. Aspinall
- †VA Pharmacy Benefits Management Services, Hines, IL, USA
- ‡VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- §University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, USA
| | - Xinhua Zhao
- ‡VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Chester B. Good
- †VA Pharmacy Benefits Management Services, Hines, IL, USA
- ‡VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- §University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, USA
- ¶University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | | | | | - Vida Passero
- **VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Kenneth J. Smith
- ††University of Pittsburgh, Division of Clinical Modeling and Decision Sciences, Pittsburgh, PA, USA
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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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van Gils CWM, de Groot S, Redekop WK, Koopman M, Punt CJA, Uyl-de Groot CA. Real-world cost-effectiveness of oxaliplatin in stage III colon cancer: a synthesis of clinical trial and daily practice evidence. PHARMACOECONOMICS 2013; 31:703-718. [PMID: 23657918 DOI: 10.1007/s40273-013-0061-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Previous cost-effectiveness analyses of oxaliplatin have been based on randomised trials whereas current Dutch policy requires evidence from daily practice. The objective of this study was to examine the real-world cost-effectiveness of oxaliplatin plus fluoropyrimidines (FL) versus FL-only as adjuvant treatment of stage III colon cancer. METHODS A Markov model was developed to estimate lifetime cost and quality-adjusted life-years from a hospital perspective. The effectiveness of the oxaliplatin arm was modelled by combining published efficacy data from the pivotal clinical registration trial (MOSAIC trial) with real-world (RW) data from a Dutch population-based observational study. RW patients were categorised into "eligible" or "ineligible", depending on whether the patients fulfilled the MOSAIC trial eligibility criteria. Ineligible RW patients (18 %) had a poorer prognosis than eligible RW patients (82 %) and MOSAIC trial patients. The effectiveness of the comparator was modelled using MOSAIC trial results. All cost inputs were based on RW patients and reported in Euro 2012. Cost-effectiveness analyses were performed for four different scenarios: (1) cost-effectiveness analyses based on MOSAIC trial patients; (2) cost-effectiveness analyses using MOSAIC and eligible RW patients; (3) cost-effectiveness analyses using MOSAIC and both eligible and ineligible RW patients, assuming oxaliplatin had an equal effect in ineligible and eligible patients; (4) cost-effectiveness analyses using MOSAIC and both eligible and ineligible RW patients, assuming oxaliplatin had no effect amongst ineligibles. For each scenario, univariate and probabilistic sensitivity analyses were undertaken. RESULTS MOSAIC trial patients and eligible RW patients treated with oxaliplatin had comparable 2-year disease-free survivals (79.5 vs. 78.4 %). Oxaliplatin showed an incremental QALY gain of 1.02, 1.13, 1.17 and 0.93 and incremental cost of <euro>9,961, <euro>11,055, <euro>9,814 and <euro>11,854 in scenarios 1-4, respectively. The corresponding incremental cost-effectiveness ratios (ICERs) were <euro>9,766, <euro>9,783, <euro>8,388 and <euro>12,746 in scenarios 1-4, respectively. In all scenarios, univariate and probabilistic sensitivity analyses indicated that the ICERs are acceptable and robust under a wide range of model assumptions. CONCLUSIONS The ICERs of the different scenarios that resulted from combining MOSAIC trial data with data from Dutch daily practice all suggest that FL + oxaliplatin is cost-effective versus FL alone in the adjuvant treatment of colon cancer. This article illustrates how one could design and implement a real-world cost-effectiveness study to yield internally valid results that could also be generalisable.
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Affiliation(s)
- Chantal W M van Gils
- Department of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus University, Burgemeester Oudlaan 50, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
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Gomes M, Aldridge RW, Wylie P, Bell J, Epstein O. Cost-effectiveness analysis of 3-D computerized tomography colonography versus optical colonoscopy for imaging symptomatic gastroenterology patients. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:107-117. [PMID: 23512599 DOI: 10.1007/s40258-013-0019-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND When symptomatic gastroenterology patients have an indication for colonic imaging, clinicians have a choice between optical colonoscopy (OC) and computerized tomography colonography with three-dimensional reconstruction (3-D CTC). 3-D CTC provides a minimally invasive and rapid evaluation of the entire colon, and it can be an efficient modality for diagnosing symptoms. It allows for a more targeted use of OC, which is associated with a higher risk of major adverse events and higher procedural costs. A case can be made for 3-D CTC as a primary test for colonic imaging followed if necessary by targeted therapeutic OC; however, the relative long-term costs and benefits of introducing 3-D CTC as a first-line investigation are unknown. AIM The aim of this study was to assess the cost effectiveness of 3-D CTC versus OC for colonic imaging of symptomatic gastroenterology patients in the UK NHS. METHODS We used a Markov model to follow a cohort of 100,000 symptomatic gastroenterology patients, aged 50 years or older, and estimate the expected lifetime outcomes, life years (LYs) and quality-adjusted life years (QALYs), and costs (£, 2010-2011) associated with 3-D CTC and OC. Sensitivity analyses were performed to assess the robustness of the base-case cost-effectiveness results to variation in input parameters and methodological assumptions. RESULTS 3D-CTC provided a similar number of LYs (7.737 vs 7.739) and QALYs (7.013 vs 7.018) per individual compared with OC, and it was associated with substantially lower mean costs per patient (£467 vs £583), leading to a positive incremental net benefit. After accounting for the overall uncertainty, the probability of 3-D CTC being cost effective was around 60 %, at typical willingness-to-pay values of £20,000-£30,000 per QALY gained. CONCLUSION 3-D CTC is a cost-saving and cost-effective option for colonic imaging of symptomatic gastroenterology patients compared with OC.
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Affiliation(s)
- Manuel Gomes
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Shabaruddin FH, Chen LC, Elliott RA, Payne K. A systematic review of utility values for chemotherapy-related adverse events. PHARMACOECONOMICS 2013; 31:277-288. [PMID: 23529208 DOI: 10.1007/s40273-013-0033-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Chemotherapy offers cancer patients the potential benefits of improved mortality and morbidity but may cause detrimental outcomes due to adverse drug events (ADEs), some of which requiring time-consuming, resource-intensive and costly clinical management. To appropriately assess chemotherapy agents in an economic evaluation, ADE-related parameters such as the incidence, (dis)utility and cost of ADEs should be reflected within the model parameters. To date, there has been no systematic summary of the existing literature that quantifies the utilities of ADEs due to healthcare interventions in general and chemotherapy treatments in particular. OBJECTIVE This review aimed to summarize the current evidence base of reported utility values for chemotherapy-related ADEs. METHODS A structured electronic search combining terms for utility, utility valuation methods and generic terms for cancer treatment was conducted in MEDLINE and EMBASE in June 2011. Inclusion criteria were: (1) elicitation of utility values for chemotherapy-related ADEs and (2) primary data. Two reviewers identified studies and extracted data independently. Any disagreements were resolved by a third reviewer. RESULTS Eighteen studies met the inclusion criteria from the 853 abstracts initially identified, collectively reporting 218 utility values for chemotherapy-related ADEs. All 18 studies used short descriptions (vignettes) to obtain the utility values, with nine studies presenting the vignettes used in the valuation exercises. Of the 218 utility values, 178 were elicited using standard gamble (SG) or time trade-off (TTO) approaches, while 40 were elicited using visual analogue scales (VAS). There were 169 utility values of specific chemotherapy-related ADEs (with the top ten being anaemia [34 values], nausea and/or vomiting [32 values], neuropathy [21 values], neutropenia [12 values], diarrhoea [12 values], stomatitis [10 values], fatigue [8 values], alopecia [7 values], hand-foot syndrome [5 values] and skin reaction [5 values]) and 49 of non-specific chemotherapy-related adverse events. In most cases, it was difficult to directly compare the utility values as various definitions and study-specific vignettes were used for the ADEs of interest. LIMITATIONS This review was designed to provide an overall description of existing literature reporting utility values for chemotherapy-related ADEs. The findings were not exhaustive and were limited to publications that could be identified using the search strategy employed and those reported in the English language. CONCLUSIONS This review identified wide ranges in the utility values reported for broad categories of specific chemotherapy-related ADEs. There were difficulties in comparing the values directly as various study-specific definitions were used for these ADEs and most studies did not make the vignettes used in the valuation exercises available. It is recommended that a basic minimum requirement be developed for the transparent reporting of study designs eliciting utility values, incorporating key criteria such as reporting how the vignettes were developed and presenting the vignettes used in the valuation tasks as well as valuing and reporting the utility values of the ADE-free base states. It is also recommended, in the future, for studies valuing the utilities of chemotherapy-related ADEs to define the ADEs according to the National Cancer Institute (NCI) definitions for chemotherapy-related ADEs as the use of the same definition across studies would ease the comparison and selection of utility values and make the overall inclusion of adverse events within economic models of chemotherapy agents much more straightforward.
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Affiliation(s)
- Fatiha H Shabaruddin
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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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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Conway EL, Farmer KC, Lynch WJ, Rees GL, Wain G, Adams J. Quality of life valuations of HPV-associated cancer health states by the general population. Sex Transm Infect 2012; 88:517-21. [PMID: 22645393 PMCID: PMC3595496 DOI: 10.1136/sextrans-2011-050161] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2012] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To obtain health-related quality of life valuations (ie, utilities) for human papillomavirus (HPV)-related cancer health states of vulval, vaginal, penile, anal and oropharyngeal cancers for use in modelling cost-effectiveness of prophylactic HPV vaccination. METHODS Written case descriptions of each HPV-associated cancer describing the 'average' patient surviving after the initial cancer diagnosis and treatment were developed in consultation with oncology clinicians. A general overview, standard gamble questionnaire for each health state and a quiz was conducted in 120 participants recruited from the general population. RESULTS In the included population sample (n=99), the average age was 43 years (range = 18-70 years) with 54% men, 44% never married/43% married, 76% education beyond year 12 and 39% employed full-time. The utility values for the five health states were 0.57 (95% CI 0.52 to 0.62) for anal cancer, 0.58 (0.53 to 0.63) for oropharyngeal cancer, 0.59 (0.54 to 0.64) for vaginal cancer, 0.65 (0.60 to 0.70) for vulval cancer and 0.79 (0.74 to 0.84) for penile cancer. Participants demonstrated a very good understanding of the symptoms, diagnosis and treatment of these cancers with a mean score of 9 (SD=1.1) on a 10-item quiz. CONCLUSIONS This study provides utility estimates for the specific HPV-related cancers of vulval, vaginal, penile, anal and oropharyngeal cancers valued by a general population sample using standard gamble. The results demonstrate considerable quality of life impact associated with surviving these cancers that will be important to incorporate into modelling cost-effectiveness of prophylactic HPV vaccination in different populations.
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Affiliation(s)
- E Lynne Conway
- CSL Biotherapies, 45 Poplar Road, Parkville, VIC 3052, Australia.
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Cost-effectiveness of computed tomography colonography in colorectal cancer screening: a systematic review. Int J Technol Assess Health Care 2012; 28:415-23. [PMID: 23006522 DOI: 10.1017/s0266462312000542] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The European Code Against Cancer recommends individuals aged ≥ 50 should participate in colorectal cancer screening. CT-colonography (CTC) is one of several screening tests available. We systematically reviewed evidence on, and identified key factors influencing, cost-effectiveness of CTC screening. METHODS PubMed, Medline, and the Cochrane library were searched for cost-effectiveness or cost-utility analyses of CTC-based screening, published in English, January 1999 to July 2010. Data was abstracted on setting, model type and horizon, screening scenario(s), comparator(s), participants, uptake, CTC performance and cost, effectiveness, ICERs, and whether extra-colonic findings and medical complications were considered. RESULTS Sixteen studies were identified from the United States (n = 11), Canada (n = 2), and France, Italy, and the United Kingdom (1 each). Markov state-transition (n = 14) or microsimulation (n = 2) models were used. Eleven considered direct medical costs only; five included indirect costs. Fourteen compared CTC with no screening; fourteen compared CTC with colonoscopy-based screening; fewer compared CTC with sigmoidoscopy (8) or fecal tests (4). Outcomes assessed were life-years gained/saved (13), QALYs (2), or both (1). Three considered extra-colonic findings; seven considered complications. CTC appeared cost-effective versus no screening and, in general, flexible sigmoidoscopy and fecal occult blood testing. Results were mixed comparing CTC to colonoscopy. Parameters most influencing cost-effectiveness included: CTC costs, screening uptake, threshold for polyp referral, and extra-colonic findings. CONCLUSION Evidence on cost-effectiveness of CTC screening is heterogeneous, due largely to between-study differences in comparators and parameter values. Future studies should: compare CTC with currently favored tests, especially fecal immunochemical tests; consider extra-colonic findings; and conduct comprehensive sensitivity analyses.
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Hedden L, Kennecke H, Villa D, Johnston K, Speers C, Kovacic L, Renouf DJ, Peacock S. Incremental cost-effectiveness of the pre- and post-bevacizumab eras of metastatic colorectal cancer therapy in British Columbia, Canada. Eur J Cancer 2012; 48:1969-76. [DOI: 10.1016/j.ejca.2012.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 12/20/2011] [Accepted: 01/15/2012] [Indexed: 10/14/2022]
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Impact of comorbidity on colorectal cancer screening cost-effectiveness study in diabetic populations. J Gen Intern Med 2012; 27:730-8. [PMID: 22237663 PMCID: PMC3358394 DOI: 10.1007/s11606-011-1972-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 12/02/2011] [Accepted: 12/08/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although comorbidity has been shown to affect the benefits and risks of colorectal cancer (CRC) screening, it has not been accounted for in prior cost-effectiveness analyses of CRC screening. OBJECTIVE To evaluate the impact of diagnosis of diabetes mellitus, a highly prevalent comorbidity in U.S. adults aged 50 and older, on health and economic outcomes of CRC screening. DESIGN Cost-effectiveness analysis using an integrated modeling framework. DATA SOURCES Derived from basic and epidemiologic studies, clinical trials, cancer registries, and a colonoscopy database. TARGET POPULATION U.S. 50-year-old population. TIME HORIZON Lifetime. PERSPECTIVE Costs are based on Medicare reimbursement rates. INTERVENTIONS Colonoscopy screening at ten-year intervals, beginning at age 50, and discontinued after age 50, 60, 70, 80 or death. OUTCOME MEASURES Health outcomes and cost effectiveness. RESULTS OF BASE-CASE ANALYSIS Diabetes diagnosis significantly affects cost-effectiveness of CRC screening. For the same CRC screening strategy, a person without diabetes at age 50 gained on average 0.07-0.13 life years more than a person diagnosed with diabetes at age 50 or younger. For a population of 1,000 patients diagnosed with diabetes at baseline, increasing stop age from 70 years to 80 years increased quality-adjusted life years (QALYs) gained by 0.3, with an incremental cost-effectiveness ratio of $206,671/QALY. The corresponding figures for 1,000 patients without diabetes are 2.3 QALYs and $46,957/QALY. RESULTS OF SENSITIVITY ANALYSIS Cost-effectiveness results are sensitive to cost of colonoscopy and adherence to colonoscopy screening. LIMITATIONS Results depend on accuracy of model assumptions. CONCLUSION Benefits of CRC screening differ substantially for patients with and without diabetes. Screening for CRC in patients diagnosed with diabetes at age 50 or younger is not cost-effective beyond age 70. Screening recommendations should be individualized based on the presence of comorbidities.
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Wong G, Howard K, Chapman J, Pollock C, Chadban S, Salkeld G, Tong A, Williams N, Webster A, Craig JC. How do people with chronic kidney disease value cancer-related quality of life? Nephrology (Carlton) 2012; 17:32-41. [PMID: 22017753 DOI: 10.1111/j.1440-1797.2011.01531.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To estimate the utility-based quality of life (QOL) of people with chronic kidney disease (CKD) and to estimate the QOL associated with two hypothetical colorectal cancer health states. METHODS A cross-sectional study was conducted in people with CKD (stages 3-5, transplant recipients and those on dialysis) from three centres in Sydney, Australia. We measured participants' own QOL and that of two hypothetical colorectal cancer health states using a rating scale, and a utility-based QOL measure, the time trade-off, with extremes of 0 (death) and 1 (full health). RESULTS Recipients of kidney transplants (n=79) had the highest mean QOL weights of 0.79 (standard deviation (SD)=0.34) compared with participants with CKD 3-5 (n=53) with mean QOL weights of 0.70 (SD=0.39), and those on dialysis (n=89), who had the lowest mean QOL weights of 0.62 (SD=0.41) (P=0.02). Having early and advanced stage colorectal cancers were valued at mean QOL weights of 0.44 (SD=0.41) and 0.12 (SD=0.25) among people with moderate stage CKD; 0.45 (SD=0.39) and 0.11 (SD=0.24) among dialysis patients; 0.62 (SD=0.36) and 0.18 (SD=0.29) among kidney transplant recipients. CONCLUSIONS People with CKD have poor QOL. Having coexistent illnesses such as cancer further reduces the overall well-being of individuals with kidney disease. In addition to the development of effective screening and treatment programs to improve cancer outcomes in people with CKD, our study also highlights the need for effective interventions to improve the QOL in people with CKD, particularly those with major comorbidities like cancer.
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Affiliation(s)
- Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, School of Public Health, Sydney University, New South Wales, Australia.
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Holubar SD, Chatterjee A, Finlayson SR. Cost-Based Comparative-Effectiveness Research in Colon and Rectal Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Heilbrun ME, Yu J, Smith KJ, Dechet CB, Zagoria RJ, Roberts MS. The cost-effectiveness of immediate treatment, percutaneous biopsy and active surveillance for the diagnosis of the small solid renal mass: evidence from a Markov model. J Urol 2011; 187:39-43. [PMID: 22088331 DOI: 10.1016/j.juro.2011.09.055] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE The most effective diagnostic strategy for the very small, incidentally detected solid renal mass is uncertain. We assessed the cost-effectiveness of adding percutaneous biopsy or active surveillance to the diagnosis of a 2 cm or less solid renal mass. MATERIALS AND METHODS A Markov state transition model was developed to observe a hypothetical cohort of healthy 60-year-old men with an incidentally detected, 2 or less cm solid renal mass, comparing percutaneous biopsy, immediate treatment and active surveillance. The primary outcomes assessed were the incremental cost-effectiveness ratio measured by cost per life-year gained at a willingness to pay threshold of $50,000. Model results were assessed by sensitivity analysis. RESULTS Immediate treatment was the highest cost, most effective diagnostic strategy, providing the longest overall survival of 18.53 life-years. Active surveillance was the lowest cost, least effective diagnostic strategy. On cost-effectiveness analysis using a societal willingness to pay threshold of $50,000 active surveillance was the preferred choice at a $75,000 willingness to pay threshold while biopsy and treatment were acceptable ($56,644 and $70,149 per life-year, respectively). When analysis was adjusted for quality of life, biopsy dominated immediate treatment as the most cost-effective diagnostic strategy at $33,840 per quality adjusted life-year gained. CONCLUSIONS Percutaneous biopsy may have a greater role in optimizing the diagnosis of an incidentally detected, 2 cm or less solid renal mass.
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Affiliation(s)
- Marta E Heilbrun
- Department of Radiology and Division of Urology, University of Utah, Salt Lake City, Utah, USA.
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Wilschut JA, Habbema JDF, van Leerdam ME, Hol L, Lansdorp-Vogelaar I, Kuipers EJ, van Ballegooijen M. Fecal occult blood testing when colonoscopy capacity is limited. J Natl Cancer Inst 2011; 103:1741-51. [PMID: 22076285 DOI: 10.1093/jnci/djr385] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Fecal occult blood testing (FOBT) can be adapted to a limited colonoscopy capacity by narrowing the age range or extending the screening interval, by using a more specific test or hemoglobin cutoff level for referral to colonoscopy, and by restricting surveillance colonoscopy. Which of these options is most clinically effective and cost-effective has yet to be established. METHODS We used the validated MISCAN-Colon microsimulation model to estimate the number of colonoscopies, costs, and health effects of different screening strategies using guaiac FOBT or fecal immunochemical test (FIT) at various hemoglobin cutoff levels between 50 and 200 ng hemoglobin per mL, different surveillance strategies, and various age ranges. We optimized the allocation of a limited number of colonoscopies on the basis of incremental cost-effectiveness. RESULTS When colonoscopy capacity was unlimited, the optimal screening strategy was to administer an annual FIT with a 50 ng/mL hemoglobin cutoff level in individuals aged 45-80 years and to offer colonoscopy surveillance to all individuals with adenomas. When colonoscopy capacity was decreasing, the optimal screening adaptation was to first increase the FIT hemoglobin cutoff value to 200 ng hemoglobin per mL and narrow the age range to 50-75 years, to restrict colonoscopy surveillance, and finally to further decrease the number of screening rounds. FIT screening was always more cost-effective compared with guaiac FOBT. Doubling colonoscopy capacity increased the benefits of FIT screening up to 100%. CONCLUSIONS FIT should be used at higher hemoglobin cutoff levels when colonoscopy capacity is limited compared with unlimited and is more effective in terms of health outcomes and cost compared with guaiac FOBT at all colonoscopy capacity levels. Increasing the colonoscopy capacity substantially increases the health benefits of FIT screening.
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Affiliation(s)
- Janneke A Wilschut
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
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97
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Wilschut JA, Hol L, Dekker E, Jansen JB, Van Leerdam ME, Lansdorp-Vogelaar I, Kuipers EJ, Habbema JDF, Van Ballegooijen M. Cost-effectiveness analysis of a quantitative immunochemical test for colorectal cancer screening. Gastroenterology 2011; 141:1648-55.e1. [PMID: 21784045 DOI: 10.1053/j.gastro.2011.07.020] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 06/29/2011] [Accepted: 07/18/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Two European randomized trials (N = 30,000) compared guaiac fecal occult blood testing with quantitative fecal immunochemical testing (FIT) and showed better attendance rates and test characteristics for FIT. We aimed to identify the most cost-effective FIT cutoff level for referral to colonoscopy based on data from these trials and allowing for differences in screening ages. METHODS We used the validated MIcrosimulation SCreening ANalysis (MISCAN)-Colon microsimulation model to estimate costs and effects of different screening strategies for FIT cutoff levels of 50, 75, 100, 150, and 200 ng/mL hemoglobin. For each cutoff level, screening strategies were assessed with various age ranges and screening intervals. We assumed sufficient colonoscopy capacity for all strategies. RESULTS At all cost levels, FIT screening was most effective with the 50 ng/mL cutoff level. The incremental cost-effectiveness ratio of biennial screening between ages 55 and 75 years using FIT at 50 ng/mL, for example, was 3900 euro per life year gained. Annual screening had an incremental cost-effectiveness ratio of 14,900 euro per life year gained, in combination with a wider age range (between ages 45 and 80 years). In the sensitivity analysis, 50 ng/mL remained the preferred cutoff level. CONCLUSIONS FIT screening is more cost-effective at a cutoff level of 50 ng/mL than at higher cutoff levels. This supports the recommendation to use FIT at a cutoff level of 50 ng/mL, which is considerably lower than the values used in current practice.
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Affiliation(s)
- Janneke A Wilschut
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
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98
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Mullins CD, Hsiao FY, Onukwugha E, Pandya NB, Hanna N. Comparative and cost-effectiveness of oxaliplatin-based or irinotecan-based regimens compared with 5-fluorouracil/leucovorin alone among US elderly stage IV colon cancer patients. Cancer 2011; 118:3173-81. [PMID: 22020739 DOI: 10.1002/cncr.26613] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Revised: 08/11/2011] [Accepted: 08/29/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND Clinical trials have shown a statistically significant disease-free survival benefit of oxaliplatin-based or irinotecan-based combination regimens for stage IV colon cancer. Less is known regarding the comparative effectiveness and cost-effectiveness of these agents among elderly patients. Whether the benefits of these agents justify the additional costs for elderly Medicare recipients is particularly policy relevant after US health care reform. METHODS A cost-effectiveness analysis of oxaliplatin-based or irinotecan-based combination therapy versus 5-fluorouracil/leucovorin alone in elderly stage IV colon cancer patients was performed from a US Medicare perspective. Survival and direct medical costs were estimated using Surveillance, Epidemiology, and End Results-Medicare data sets for patients diagnosed from 2002 to 2005 with follow-up through 2007. Incremental cost-effectiveness ratios (ICERs) were calculated as costs per life-year gained, with sensitivity analysis estimating the cost per quality-adjusted life-year (QALY). RESULTS Median improved overall survival with 5-fluorouracil/leucovorin alone, or irinotecan-based or oxaliplatin-based combination therapy was 0.99, 1.07, and 1.47 life-years, respectively. Costs per life-year gained for oxaliplatin-based or irinotecan-based combination regimens compared with 5-fluorouracil/leucovorin alone were $78,181 and $267,938, respectively. ICERs comparing oxaliplatin-based to irinotecan-based regimens were $40,230 per life-year gained or $160,920 per QALY. CONCLUSIONS Oxaliplatin-based or irinotecan-based combination therapy improves overall survival but also substantially increases direct medical costs compared with 5-fluorouracil/leucovorin alone when used in elderly US patients with stage IV colon cancer. Oxaliplatin-based regimens are more cost-effective than irinotecan-based regimens for treatment of elderly stage IV colon cancer patients in terms of cost per life-year gained, but not in terms of cost per QALY.
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Affiliation(s)
- C Daniel Mullins
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, Maryland 21201, USA.
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99
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Squires H, Tappenden P, Cooper K, Carroll C, Logan R, Hind D. Cost-Effectiveness of Aspirin, Celecoxib, and Calcium Chemoprevention for Colorectal Cancer. Clin Ther 2011; 33:1289-305. [DOI: 10.1016/j.clinthera.2011.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 07/08/2011] [Accepted: 07/13/2011] [Indexed: 01/09/2023]
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100
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Attard CL, Maroun JA, Alloul K, Grima DT, Bernard LM. Cost-effectiveness of oxaliplatin in the adjuvant treatment of colon cancer in Canada. ACTA ACUST UNITED AC 2011; 17:17-24. [PMID: 20179799 PMCID: PMC2826771 DOI: 10.3747/co.v17i1.436] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective The cost-effectiveness of oxaliplatin in combination with 5-fluorouracil/leucovorin (5fu/lv)—the folfox regimen—was compared with that of 5fu/lv alone as adjuvant therapy for patients with stage iii colon cancer, from the perspective of the Cancer Care Ontario New Drug Funding Program. In the mosaic (Multicenter International Study of Oxaliplatin/5-Fluorouracil/Leucovorin in the Adjuvant Treatment of Colon Cancer) trial, the folfox regimen significantly improved disease-free survival. The mosaic trial formed the basis of the present analysis. Methodology Extrapolated patient-level data from the mosaic trial were used to model patient outcomes from treatment until death. Utilities were obtained from the literature. Resource utilization data were derived from the mosaic trial and supplemented with data from the literature. Unit costs were obtained from the Ontario Ministry of Health and Long-Term Care, the London Health Sciences Centre, and the literature. Results Lifetime incremental cost-effectiveness ratios for folfox compared with 5fu/lv were CA$14,266 per disease-free year, CA$23,598 per life-year saved, and CA$24,104 per quality adjusted life-year (qaly) gained, discounting costs and outcomes at 5% per annum. These results were stable for a wide range of inputs; only utility values associated with relapse seemed to influence the cost-effectiveness ratios observed. Conclusions With an incremental cost of CA$24,104 per qaly gained, folfox is a cost-effective adjuvant treatment for stage iii colon cancer. Compared with 5fu/lv alone, this regimen offers better clinical outcomes and provides good value for money.
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Affiliation(s)
- C L Attard
- Cornerstone Research Group Inc., Burlington, ON
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