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El Deen Alkhadraa I, Uebel L, Kromodikoro I, van Nieuwenhoven M. Differential Outcomes in Colorectal Cancer Detection: A Comparative Study of Swedish Nationwide Screening and Fast-Track Diagnostic Pathways. J Clin Gastroenterol 2024:00004836-990000000-00344. [PMID: 39212999 DOI: 10.1097/mcg.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 08/09/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND In 2021, a nation-wide screening program for colorectal cancer (CRC) was step-wise implemented in Region Örebro County (RÖC) for patients aged 60 to 74 years, utilizing the fecal immunochemical test (FIT) to refer patients for colonoscopy. Concurrently, the standardized care course for colorectal cancer (SCC-CRC), initiated in 2016, employs a fast-track pathway for patients with alarm symptoms to undergo colonoscopy. This study compares CRC screening colonoscopies with SCC-CRC colonoscopies in RÖC among patients aged 60 to 67 years. METHODS An initial analysis of the Swedish colorectal screening cohort was combined with a retrospective cohort study, analyzing data from 307 CRC screening patients and 441 age-matched SCC-CRC patients in RÖC. Data included demographics, colonoscopy participation rates, and pathology findings. Statistical analyses compared outcomes between the 2 groups. RESULTS Among the screening group, 2% tested positive for FIT, with an 86% colonoscopy participation rate (N=9296). In RÖC, 266 screening patients underwent colonoscopy, with 10% diagnosed with CRC, compared with 20% in the SCC-CRC group. In addition, 39% of the screening group in RÖC were diagnosed with advanced adenomas, versus 15% in the SCC-CRC group. CONCLUSIONS Screening participation was high, with effectiveness aligning with international counterparts. The SCC-CRC pathway excels in diagnosing CRC among symptomatic patients, while the nationwide screening program is effective in early detection of CRC and advanced adenomas. underscoring the importance of integrating and optimizing both approaches within the Swedish health care system to optimize CRC prevention and management.
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Affiliation(s)
- Izz El Deen Alkhadraa
- Department of Internal Medicine, Faculty of Medicine and Health, Division of Gastroenterology Örebro University
| | - Linnea Uebel
- Department of Internal Medicine, Faculty of Medicine and Health, Division of Gastroenterology Örebro University
| | - Indy Kromodikoro
- Department of Internal Medicine, Faculty of Medicine and Health, Division of Gastroenterology Örebro University
| | - Michiel van Nieuwenhoven
- Department of Internal Medicine, Faculty of Medicine and Health, Division of Gastroenterology Örebro University
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
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Ishibashi F, Suzuki S, Kobayashi K, Tanaka R, Kawakami T, Mochida K, Nagai M, Ishibashi Y, Morishita T. Cost-effectiveness analysis of single colonoscopy versus single fecal test for colorectal cancer diagnosis and treatment. J Gastroenterol Hepatol 2024; 39:1328-1335. [PMID: 38348570 DOI: 10.1111/jgh.16509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND AND AIM Regular endoscopy or fecal immunochemical test (FIT) is ideal for screening colorectal cancer. However, only a limited number of individuals undergo regular screening. This study aimed to compare the cost-effectiveness of a single colonoscopy with a single FIT performed for colorectal cancer screening. METHODS A microsimulation model was constructed based on real-world observational data collected from three institutions between 2019 and 2022 that compared colonoscopy-based screening with FIT-based screening. The total costs of diagnosis and treatment of the detected lesions using the two strategies were calculated. The incremental cost-effectiveness ratio (ICER) per life year gained (LYG) of the colonoscopy-based strategy was calculated. RESULTS Data from 11 407 patients undergoing colonoscopies and 59 176 patients undergoing FITs were used to establish a model. In the base case analysis of screening strategies, colonoscopy was more cost-effective than FIT (ICER 415 193 yen/LYG). The ICER of the colonoscopy-based strategy among 60- to 69-year-old patients was lowest at 394 200 yen/LYG, whereas that in 20- to 29-year-old patients was highest. Monte Carlo simulations showed that the colonoscopy-based strategy was more cost-effective than the FIT-based strategy (net monetary benefit [NMB]: 5 695 957 yen vs 5 348 253 yen). When the adenoma detection rate in the colonoscopy was over 30% or the positive FIT rate was lower than 8.6% in the FIT-based strategy, the NMB of the colonoscopy-based strategy exceeded that of the FIT-based strategy. CONCLUSION In the microsimulation model, colonoscopy is recommended as a one-time screening procedure in patients aged >60 years with >30% ADR or <8.6% positive FIT rate.
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Affiliation(s)
- Fumiaki Ishibashi
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
- Endoscopy Center, Koganei Tsurukame Clinic, Tokyo, Japan
| | - Sho Suzuki
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | | | - Ryu Tanaka
- Digestive Disease Center, Shinjuku Tsurukame Clinic, Tokyo, Japan
| | | | - Kentaro Mochida
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
- Endoscopy Center, Koganei Tsurukame Clinic, Tokyo, Japan
| | - Mizuki Nagai
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
| | - Yuichi Ishibashi
- Research and Development Initiative, Chuo University, Tokyo, Japan
| | - Tetsuo Morishita
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba, Japan
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Bonander C, Westerberg M, Chauca Strand G, Forsberg A, Strömberg U. Colorectal cancer screening with fecal immunochemical testing or primary colonoscopy: inequities in diagnostic yield. JNCI Cancer Spectr 2024; 8:pkae043. [PMID: 38830030 PMCID: PMC11187582 DOI: 10.1093/jncics/pkae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/15/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Socioeconomic inequalities in the uptake of colorectal cancer screening are well documented, but the implications on inequities in health gain remain unclear. METHODS Sixty-year-olds were randomly recruited from the Swedish population between March 2014 and March 2020 and invited to undergo either 2 rounds of fecal immunochemical testing (FIT) 2 years apart (n = 60 137) or primary colonoscopy just once (n = 30 400). By linkage to Statistics Sweden's registries, we obtained socioeconomic data. In each defined socioeconomic group, we estimated the cumulative yield of advanced neoplasia in each screening arm (intention-to-screen analysis). In the biennial FIT arm, we predicted the probability of exceeding the yield in the primary colonoscopy arm by linear extrapolation of the cumulative yield to (hypothetical) additional rounds of FIT. RESULTS In the lowest income group, the yield of advanced neoplasia was 1.63% (95% confidence interval [CI] = 1.35% to 1.93%) after 2 rounds of FIT vs 1.93% (95% CI = 1.49% to 2.40%) in the primary colonoscopy arm. Extrapolation to a third round of FIT implied a 86% probability of exceeding the yield in the primary colonoscopy arm. In the highest income group, we found a more pronounced yield gap between the 2 screening strategies-2.32% (95% CI = 2.15% to 2.49%) vs 3.71% (95% CI = 3.41% to 4.02%)- implying a low (2%) predicted probability of exceeding yield after a third round of FIT. CONCLUSIONS Yield of advanced neoplasia from 2 rounds of FIT 2 years apart was poorer as compared with primary colonoscopy, but the difference was less in lower socioeconomic groups. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02078804.
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Affiliation(s)
- Carl Bonander
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Marcus Westerberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Medicine K2, Karolinska Institutet, Solna, Sweden
| | - Gabriella Chauca Strand
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Anna Forsberg
- Department of Medicine K2, Karolinska Institutet, Solna, Sweden
| | - Ulf Strömberg
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Sweden
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Pokharel R, Lin YS, McFerran E, O'Mahony JF. A Systematic Review of Cost-Effectiveness Analyses of Colorectal Cancer Screening in Europe: Have Studies Included Optimal Screening Intensities? APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:701-717. [PMID: 37380865 PMCID: PMC10403417 DOI: 10.1007/s40258-023-00819-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE To assess the range of strategies analysed in European cost-effectiveness analyses (CEAs) of colorectal cancer (CRC) screening with respect to the screening intervals, age ranges and test cut-offs used to define positivity, to examine how this might influence what strategies are found to be optimal, and compare them with the current screening policies with a focus on the screening interval. METHODS We searched PubMed, Web of Science and Scopus for peer-reviewed, model-based CEAs of CRC screening. We included studies on average-risk European populations using the guaiac faecal occult blood test (gFOBT) or faecal immunochemical test (FIT). We adapted Drummond's ten-point checklist to appraise study quality. RESULTS We included 39 studies that met the inclusion criteria. Biennial screening was the most frequently used interval which was analysed in 37 studies. Annual screening was assessed in 13 studies, all of which found it optimally cost-effective. Despite this, 25 of 26 European stool-based programmes use biennial screening. Many CEAs did not vary the age range, but the 14 that did generally found broader ranges optimal. Only 11 studies considered alternative FIT cut-offs, 9 of which found lower cut-offs superior. Conflicts between current policy and CEA evidence are less clear regarding age ranges and cut-offs. CONCLUSIONS The existing CEA evidence indicates that the widely adopted biennial frequency of stool-based testing in Europe is suboptimal. It is likely that many more lives could be saved throughout Europe if programmes could be offered with more intensive annual screening.
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Affiliation(s)
- Rajani Pokharel
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Yi-Shu Lin
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Ethna McFerran
- Patrick G Johnston Centre for Cancer Research, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - James F O'Mahony
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
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Yaghoobi M, Mehraban Far P, Mbuagbaw L, Yuan Y, Armstrong D, Thabane L, Moayyedi P. Head-to-Head Diagnostic Test Accuracy Meta-analysis of Colonoscopy and Fecal Immunochemical Test in Detecting Advanced Colon Neoplasia. Middle East J Dig Dis 2023; 15:5-11. [PMID: 37547158 PMCID: PMC10404074 DOI: 10.34172/mejdd.2023.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 10/10/2022] [Indexed: 08/08/2023] Open
Abstract
Background: Studies on the use of fecal immunochemical test (FIT) in colorectal screening have long assumed perfect accuracy for colonoscopy. No study to date has directly compared the diagnostic accuracy of colonoscopy and FIT to detect advanced neoplasia (AN) in a head-to-head diagnostic accuracy meta-analysis. Methods: A comprehensive electronic search was performed for a head-to-head comparison of FIT and colonoscopy using a third acceptable reference standard in asymptomatic adults. Cochrane methodology was used to perform a head-to-head diagnostic test accuracy (DTA) meta-analysis. Quality assessment tool for diagnostic accuracy studies-2 (QUADAS-2) was used to assess the risk of bias in included studies. Results: Two studies met the eligibility criteria. Overall sensitivity and specificity were 98.5 (95% CI 96.3-100%) and 100% (99.9-100%) for colonoscopy and 16.4% (10.3-22.6%) and 95.4% (94.3-96.4%) for FIT. Colonoscopy was significantly better than FIT (P < 0.0001). The positive and negative likelihood ratios (LRs) were 1.75 (1.57-1.96) and 0.03 (0.01-0.08) for colonoscopy and 3.02 (2.01-4.55) and 0.88 (0.82-0.95) for FIT, respectively. Conclusion: Colonoscopy provides significantly better diagnostic accuracy to detect AN compared with FIT (GRADE: ⨁⨁◯◯). Our study provided precise sensitivity and specificity of both colonoscopy and FIT and a revision in screening policies based on an updated cost-effectiveness analysis considering the results of the head-to-head analysis.
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Affiliation(s)
- Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Cochrane GUT, Hamilton, Ontario, Canada
- The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Parsa Mehraban Far
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Division of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Biostatistics Unit/The Research Institute, St Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Cochrane GUT, Hamilton, Ontario, Canada
- The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Biostatistics Unit/The Research Institute, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Departments of Anesthesia/Pediatrics; Schools of Nursing/Rehabilitation Sciences, Master University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Cochrane GUT, Hamilton, Ontario, Canada
- The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
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Yaghoobi M, Mehraban Far P, Mbuagbaw L, Yuan Y, Armstrong D, Thabane L, Moayyedi P. Potential Modifiers and Different Cut-offs in Diagnostic Accuracy of Fecal Immunochemical Test in Detecting Advanced Colon Neoplasia: A Diagnostic Test Accuracy Meta-analysis. Middle East J Dig Dis 2022; 14:382-395. [PMID: 37547494 PMCID: PMC10404105 DOI: 10.34172/mejdd.2022.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/29/2022] [Indexed: 08/08/2023] Open
Abstract
Background: Fecal immunoglobulin test (FIT) has been advocated as the first line of screening for colorectal cancer (CRC) in several jurisdictions. Most studies have focused on CRC as the outcome of interest. Our goal was to quantify the diagnostic accuracy of different thresholds of FIT as compared with colonoscopy for detection of advanced colonic neoplasia and potential modifiers using proper Cochrane methodology. Methods: A comprehensive electronic search was performed for studies on FIT using colonoscopy as the reference standard to detect advanced neoplasia. Cochrane methodology was used to perform a diagnostic test accuracy (DTA) meta-analysis. Diagnostic accuracy of different cut-offs of FIT, including 25, 50, 75, 100, 150, and 200 ng/mL, were calculated separately. Meta-regression analysis was also performed to detect potential a priori modifiers, including age, location of the tumor, and time from FIT to colonoscopy. Results: Twenty-four studies were included with no evidence of publication bias. The sensitivity of FIT did not decrease with lowering the cut-off, although specificity increased in higher cut-offs. Commonly used cut-offs of 50 ng/mL, 75 ng/mL, and 100 ng/mL for FIT provided sensitivity of 39%, 36%, 27% and specificity of 92%, 94%, 96%, respectively. Diagnostic accuracy of FIT did not significantly differ in proximal versus distal lesions or in individuals below or over the age of 50 years. The results remained robust in a meta-regression of the location of the study, time from FIT to colonoscopy, and methodological quality. Conclusion: The sensitivity of FIT might have been overestimated in previous studies focusing on CRC, and it seems to be independent of age, location of neoplasia, or cut-offs, contrary to some previous studies. Lowering the cut-off will reduce the diagnostic odds ratio (DOR) by increasing specificity but without any effect on sensitivity.
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Affiliation(s)
- Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Cochrane GUT, Hamilton, Ontario, Canada
- The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Parsa Mehraban Far
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Division of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Biostatistics Unit/The Research Institute, St Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Cochrane GUT, Hamilton, Ontario, Canada
- The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Biostatistics Unit/The Research Institute, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Departments of Anesthesia/Pediatrics; Schools of Nursing/Rehabilitation Sciences, Master University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Cochrane GUT, Hamilton, Ontario, Canada
- The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
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Ren Y, Zhao M, Zhou D, Xing Q, Gong F, Tang W. Cost-effectiveness analysis of colonoscopy and fecal immunochemical testing for colorectal cancer screening in China. Front Public Health 2022; 10:952378. [PMID: 36033786 PMCID: PMC9412186 DOI: 10.3389/fpubh.2022.952378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/22/2022] [Indexed: 01/24/2023] Open
Abstract
Objective This study aimed to evaluate the cost-effectiveness of the colorectal cancer screening in China, and that when the screening was implemented in a specific region. Methods A 13-state Markov model was established to compare four screening protocols, including annual fecal immunochemical testing (FIT1), biennial fecal immunochemical testing (FIT2), electronic colonoscopy every 10 years (e-CSPY10), and electronic colonoscopy every 5 years (e-CSPY5), with no screening from the perspective of Chinese healthcare system. The model simulated the health states of a cohort of 100,000 average-risk individuals aging from 50 to 75. Additionally, scenarios including the implementation in a specific region, starting from 40, and incompletely successful treatment of cancer were also analyzed. Results Annual and biennial FIT could save 8.13USD (US Dollar) and 44.96USD per person, and increase 0.0705QALYs (Quality-Adjusted Life Years) and 0.2341 QALYs compared with no screening, respectively. Annual FIT could decrease costs by 36.81USD per person and increase 0.1637 QALYs in comparison to biennial FIT. The results showed that both annual and biennial FIT for screening were dominant over no screening, and annual FIT was dominant over biennial FIT. The ICER (Incremental Cost-Effectiveness Ratio) for e-CSPY10 were 1183.51USD/QALY and 536.66USD/QALY compared with FIT1 and FIT2. The ICER for e-CSPY5 were 1158.16USD/QALY and 770.85USD/QALY compared with FIT1 and FIT2. And the ICER for e-CSPY5 relative to e-CSPY10 was 358.71USD/QALY. All the ICER values were lower than the economic threshold of 2021 Chinese GDP (Gross Domestic Product) per capita in 2021(12554.42USD). Conclusions It is worthwhile to popularize CRC screening in mainland China, as FIT always saving costs and colonoscopy is cost-effective. Regions with high income can take electronic colonoscopy every 10 years, or even every 5 years into consideration when determining the specific strategies.
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Affiliation(s)
- Yinan Ren
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
| | - Mingye Zhao
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
| | - Dachuang Zhou
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
| | - Qian Xing
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
| | - Fangfang Gong
- Department of Hospital Group Office, Shenzhen Luohu Hospital Group Luohu People's Hospital (The Third Affiliated Hospital of Shenzhen University), Shenzhen, China
| | - Wenxi Tang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
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Strömberg U, Bonander C, Westerberg M, Levin L, Metcalfe C, Steele R, Holmberg L, Forsberg A, Hultcrantz R. Colorectal cancer screening with fecal immunochemical testing or primary colonoscopy: An analysis of health equity based on a randomised trial. EClinicalMedicine 2022; 47:101398. [PMID: 35480071 PMCID: PMC9035727 DOI: 10.1016/j.eclinm.2022.101398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/28/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We have addressed health equity attained by fecal immunochemical testing (FIT) and primary colonoscopy (PCOL), respectively, in the randomised controlled screening trial SCREESCO conducted in Sweden. METHODS We analysed data on the individuals recruited between March 2014, and March 2020, within the study registered with ClinicalTrials.gov, NCT02078804. Swedish population registry data on educational level, household income, country of birth, and marital status were linked to each 60-year-old man and woman who had been randomised to two rounds of FIT 2 years apart (n = 60,123) or once-only PCOL (n = 30,390). Furthermore, we geo-coded each study individual to his/her residential area and assessed neighbourhood-level data on deprivation, proportion of non-Western immigrants, population density, and average distance to healthcare center for colonoscopy. We estimated adjusted associations of each covariate with the colonoscopy attendance proportion out of all invited to respective arms; ie, the preferred outcome for addressing health equity. In the FIT arm, the test uptake and the colonoscopy uptake among the test positives were considered as the secondary outcomes. FINDINGS We found a marked socioeconomic gradient in the colonoscopy attendance proportion in the PCOL arm (adjusted odds ratio [95% credibility interval] between the groups categorised in the highest vs. lowest national quartile for household income: 2·20 [2·01-2·42]) in parallel with the gradient in the test uptake of the FIT × 2 screening (2·08 [1·96-2·20]). The corresponding gradient in the colonoscopy attendance proportion out of all invited to FIT was less pronounced (1·29 [1·16-1·42]), due to higher proportions of FIT positives in socioeconomically disadvantaged groups. INTERPRETATION The unintended risk of exacerbating inequalities in health by organised colorectal cancer screening may be higher with a PCOL strategy than a FIT strategy, despite parallel socioeconomic gradients in uptake. FUNDING This work was supported by the Swedish Cancer Society under Grant 20 0719. CB and US provided economic support from the Swedish Research Council for Health, Working life, and Welfare under Grant 2020-00962.
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Affiliation(s)
- U. Strömberg
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, PO Box 463, Gothenburg SE-405 30, Sweden
- Corresponding author.
| | - C. Bonander
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, PO Box 463, Gothenburg SE-405 30, Sweden
| | - M. Westerberg
- Department of Mathematics, Uppsala University, Box 480, Uppsala SE-751 06, Sweden
| | - L.Å. Levin
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping SE-581 83, Sweden
| | - C. Metcalfe
- Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, United Kingdom
| | - R. Steele
- Department of Surgery, Population Health and Genomics, School of Medicine, University of Dundee, Ninewells Hospital, Dundee DD1 9SY, United Kingdom
| | - L. Holmberg
- Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King's College London, Guy's Hospital, St Thomas Street, London SE1 9RT, United Kingdom
- Department of Surgical Sciences, Uppsala University, Uppsala SE-751 85, Sweden
| | - A. Forsberg
- Department of Medicine K2, Solna, Karolinska Institutet, Stockholm SE-171 76, Sweden
| | - R. Hultcrantz
- Department of Medicine K2, Solna, Karolinska Institutet, Stockholm SE-171 76, Sweden
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Heinävaara S, Gini A, Sarkeala T, Anttila A, de Koning H, Lansdorp-Vogelaar I. Optimizing screening with faecal immunochemical test for both sexes - Cost-effectiveness analysis from Finland. Prev Med 2022; 157:106990. [PMID: 35150749 DOI: 10.1016/j.ypmed.2022.106990] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/30/2021] [Accepted: 02/06/2022] [Indexed: 11/28/2022]
Abstract
A faecal immunochemical test (FIT) screening pilot was introduced in Finland in 2019 with sex-specific screening strategies. This study aims to model cost-effectiveness of sex-specific strategies for the whole population, and to assess whether the current strategies are optimal. We developed separate MISCAN-Colon models, including different FIT performances, for the Finnish men and women using the first-year data of the FIT screening pilot. We evaluated 180 FIT strategies varying in FIT cut-off, screening interval, age to start, and age to stop screening, and compared them to no-screening by sex. We used incremental cost-effectiveness ratios (ICERs) to identify the optimal strategy after combining all male and female strategies and restricting the analysis by costs and referral rate to diagnostic colonoscopies. Offering annual FIT screening with a cut-off of 25 μg/g at 50-79 years in men and with a cut-off of 10 μg/g at 55-69 years in women was optimal. This combined strategy prevented 28% of colorectal cancer (CRC) cases and 55% of CRC deaths with acceptable costs (ICER = 9000€/life-years gained). Screening at the current target age of 60-74 years was suboptimal for both sexes. Among strategies with the same target age and interval for both sexes, expected benefits from optimal screening were lower but still reasonable. Our results support a wider age range of screening in men, and a lower cut-off for a positive test in women when restrictions on colonoscopy capacity and costs are in place. National FIT screening program should start at younger age.
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Affiliation(s)
- Sirpa Heinävaara
- Finnish Cancer Registry, Cancer Society of Finland, Unioninkatu 22, 00130 Helsinki, Finland; Department of Public Health, 00014 University of Helsinki, Finland.
| | - Andrea Gini
- Department of Public Health, Erasmus Medical Center, P.O.Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Tytti Sarkeala
- Finnish Cancer Registry, Cancer Society of Finland, Unioninkatu 22, 00130 Helsinki, Finland
| | - Ahti Anttila
- Finnish Cancer Registry, Cancer Society of Finland, Unioninkatu 22, 00130 Helsinki, Finland
| | - Harry de Koning
- Department of Public Health, Erasmus Medical Center, P.O.Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus Medical Center, P.O.Box 2040, 3000 CA Rotterdam, the Netherlands
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10
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Vanaclocha-Espi M, Ibáñez J, Molina-Barceló A, Valverde-Roig MJ, Nolasco A, Pérez-Riquelme F, de la Vega M, Portillo I, Salas D. Optimal cut-off value for detecting colorectal cancer with fecal immunochemical tests according to age and sex. PLoS One 2021; 16:e0254021. [PMID: 34270590 PMCID: PMC8284629 DOI: 10.1371/journal.pone.0254021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/17/2021] [Indexed: 01/22/2023] Open
Abstract
In the fecal immunological test, a suitable cut-off value may be selected to classify results as either positive or negative. Our aim is to estimate the optimal cut-off value for detecting colorectal cancer in different age and sex groups. This is a multicentric retrospective cohort study of participants in CRC screening programs with FIT between 2006 and 2012. A total of 545,505 participations were analyzed. Cancers diagnosed outside of the program were identified after a negative test result (IC_test) up until 2014. The Wilcoxon test was used to compare fecal hemoglobin levels. ROC curves were used to identify the optimal cut-off value for each age and sex group. Screening program results were estimated for different cut-off values. The results show that the Hb concentration was higher in colorectal cancer (average = 179.6μg/g) vs. false positives (average = 55.2μg/g), in IC_test (average = 3.1μg/g) vs. true negatives (average = 0μg/g), and in men (average = 166.2μg/g) vs. women (average = 140.2μg/g) with colorectal cancer. The optimal cut-off values for women were 18.3μg/g (50-59y) and 14.6μg/g (60-69y), and 16.8μg/g (50-59y) and 19.9μg/g (60-69y) for men. Using different cut-off values for each age and sex group lead to a decrease in the IC_test rate compared to the 20μg/g cut-off value (from 0.40‰ to 0.37‰) and an increase in the false positive rate (from 6.45% to 6.99%). Moreover, test sensitivity improved (90.7%), especially in men and women aged 50-59y (89.4%; 90%) and women aged 60-69y (90.2%). In conclusion, the optimal cut-off value varies for different sex and age groups and the use of an optimal cut-off value for each group improves sensitivity and leads to a small decrease in IC_tests, but also to a larger increase in false positives.
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Affiliation(s)
- Mercedes Vanaclocha-Espi
- Foundation for the Promotion of Health and Biomedical Research-Public Health Research FISABIO–Public Health Research, Valencia, Spain
| | - Josefa Ibáñez
- Foundation for the Promotion of Health and Biomedical Research-Public Health Research FISABIO–Public Health Research, Valencia, Spain
- General Directorate Public Health, Valencian Community, Spain
| | - Ana Molina-Barceló
- Foundation for the Promotion of Health and Biomedical Research-Public Health Research FISABIO–Public Health Research, Valencia, Spain
| | | | | | - Francisco Pérez-Riquelme
- General Directorate of Public Health, Murcia Region, Spain
- Biomedical Research Institute of Murcia (IMIB-Arrixaca-UMU), University Hospital “Virgen de la Arrixaca”, University of Murcia, Murcia, Spain
| | | | | | - Dolores Salas
- Foundation for the Promotion of Health and Biomedical Research-Public Health Research FISABIO–Public Health Research, Valencia, Spain
- General Directorate Public Health, Valencian Community, Spain
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11
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Ribbing Wilén H, Saraste D, Blom J. Gender-specific cut-off levels in colorectal cancer screening with fecal immunochemical test: A population-based study of colonoscopy findings and costs. J Med Screen 2021; 28:439-447. [PMID: 34106777 DOI: 10.1177/09691413211020035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE In the population-based Swedish regional colorectal cancer (CRC) screening program of Stockholm-Gotland using the fecal immunochemical test (FIT), gender-specific cut-off levels of fecal hemoglobin are applied, since previous studies have indicated a lower sensitivity of FIT for CRC in women. The aim was to evaluate the diagnostic yield and the screening costs overall and per detected CRC of this strategy. METHODS All individuals aged 60-69 invited to screening in 2015-2017 were included. Cut-off level for positive FIT was 40 µg/g in women and 80 µg/g in men. Those with a positive FIT were referred to colonoscopy. The yield of CRC and screening cost for the study period were assessed and compared to cut-off levels of 80 µg/g in both genders. RESULTS Approximately 230,000 individuals were invited. Overall participation rates were 72% in women and 65% in men (p < 0.05). FIT was positive in 4256 individuals (2.7% in both genders). In 3758 colonoscopies, 258 (6.9%) CRCs were detected. The positive predictive value for CRC was significantly higher in men (8.3% vs. 5.8%). In 120 women with CRC, 28 (23%) had FIT < 80 µg/g. Negative colonoscopies were more common in women (24% vs. 17%, p < 0.05). Total costs for the study period were 52,000,000SEK (≈5,200,000€), i.e. 16% higher compared to using cut-off levels of 80 µg/g in both genders, and corresponding to a 3% increment in cost per detected CRC. CONCLUSION The high rate of CRC detected in women in the lowest FIT category outweighs the minor reduction in screening costs if the same cut-off level was used as for men.
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Affiliation(s)
- Hanna Ribbing Wilén
- Department of Clinical Science and Education, Södersjukhuset (KI SÖS), Karolinska Institutet, Stockholm.,Trauma & Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Deborah Saraste
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Johannes Blom
- Department of Clinical Science and Education, Södersjukhuset (KI SÖS), Karolinska Institutet, Stockholm
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12
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Gogenur I, Qvortrup C. Colorectal cancer screening in Europe: what are the next steps? Lancet Oncol 2021; 22:898-899. [PMID: 34048687 DOI: 10.1016/s1470-2045(21)00276-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/29/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Ismail Gogenur
- Department of Surgery and Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Camilla Qvortrup
- Department of Oncology, Rigshospitalet, Copenhagen 2100, Denmark.
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13
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Kim YJ, Shim JI, Park E, Kang M, Kang S, Lee J, Tchoe HJ, Kong KA, Kim DH, Kim BC, Choi KS, Moon CM. Adherence to follow-up examination after positive fecal occult blood test results affects colorectal cancer mortality: A Korea population-based cohort study. Dig Liver Dis 2021; 53:631-638. [PMID: 33676856 DOI: 10.1016/j.dld.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of adherence to follow-up examination after a fecal occult blood test (FOBT) remains ill-defined. AIM To evaluate the impact of adherence to the follow-up examination on clinical outcomes in individuals with positive FOBT results. METHODS This was a retrospective cohort study involving Korean individuals aged 50 years or older who participated in the National Cancer Screening Program for CRC from 2009 to 2010. Individuals who underwent a confirmative examination within a year after positive FOBT results were included in compliant group, and those who did not were included in non-compliant group. The incidence and stage of CRC, and 5-year survival were compared between two groups. RESULTS 5,914 were diagnosed with CRC in the compliant group and 2,973 in the non-compliant group. The proportion of advanced-stage CRC was significantly higher in the non-compliant group (localized CRC 44.6% vs. 36.7% and distant CRC 8.7% vs. 12.5%, p< 0.0001). The survival probability within 5 years was 71.0% in the non-compliant group and 85.9% in the compliant group (hazard ratio 1.70, 95% CI, 1.52-1.90, p< 0.001). CONCLUSION Individuals who underwent follow-up examination 1 year or more after positive FOBT had a lower survival rate compared with that in those who underwent examination within 1 year.
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Affiliation(s)
- Yu Jin Kim
- Department of Gastroenterology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, South Korea
| | - Jeong-Im Shim
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Eunjung Park
- National Evidence-based Healthcare Collaborating Agency, South Korea.
| | - Minjoo Kang
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Sinhee Kang
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Jessie Lee
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Ha Jin Tchoe
- National Evidence-based Healthcare Collaborating Agency, South Korea
| | - Kyeong Ae Kong
- Department of Preventive Medicine, College of Medicine, Ewha Womans University, South Korea
| | - Duk Hwan Kim
- Digestive Disease Center, Department of Internal Medicine, CHA University School of Medicine, South Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Center for Cancer Prevention and Detection, Cancer Epidemiology Branch, Research Institute and Hospital, National Cancer Center, South Korea
| | - Kui Son Choi
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, South Korea
| | - Chang Mo Moon
- Department of Internal Medicine, College of Medicine, Ewha Womans University, South Korea; Inflammation-Cancer Microenvironment Research Center, College of Medicine, Ewha Womans University, Seoul, South Korea.
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14
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Hultcrantz R. Aspects of colorectal cancer screening, methods, age and gender. J Intern Med 2021; 289:493-507. [PMID: 32929813 PMCID: PMC8048936 DOI: 10.1111/joim.13171] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/27/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Colorectal cancer (CRC) is, besides breast, prostate, lung and skin cancers, the most common cancer worldwide and is suitable for screening. The incidence of CRC varies considerably in different parts of the world: in well-developed countries, the incidence is between 30 and 70 per 100 000 inhabitants, whereas in less-developed countries such as sub-Saharan Africa, it is 10-20/100 000 inhabitants. Women have a lower incidence of CRC, which is usually one-third of total incidence. Several studies have shown that it is possible to decrease mortality from CRC with about 20%, which is evidenced through the data from countries with screening programmes. Though the method of choice to identify blood samples in faecal matter is under debate, the most feasible way is to perform colonoscopy. Other methods include more advanced faecal analyses, testing for mutations from CRC, sigmoidoscopy, CT colonoscopy or optical colonoscopy. Colonoscopy is in most countries not available in sufficient amount and has to be carried out with great accuracy; otherwise, lesions will be missed to identify, thus leading to complications. Gender is an issue in CRC screening, as women have about 20% fewer colorectal adenomas and CRCs, but they also have more right-sided lesions, which are more difficult to detect with tests for faecal blood since they create less blood in faeces. Thus, other strategies may have to be developed for women in order for screening to have the same effect. It is essential to introduce colorectal cancer screening in all countries together with other clinical pieces of advice such as information on smoking, obesity and exercise in order to reduce one of the most dangerous cancers.
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Affiliation(s)
- R Hultcrantz
- From the, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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15
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Winawer SJ, Zauber AG, O’Brien MJ, Geenen J, Waye JD. The National Polyp Study at 40: challenges then and now. Gastrointest Endosc 2021; 93:720-726. [PMID: 33010298 PMCID: PMC7887080 DOI: 10.1016/j.gie.2020.09.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/25/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Sidney J. Winawer
- Gastroenterology, Hepatology and Nutrition Service,
Department of Medicine, Memorial Sloan Kettering Cancer Center
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial
Sloan Kettering Cancer
| | - Michael J. O’Brien
- Department of Laboratory Pathology, Boston University
School of Medicine
| | - Joseph Geenen
- Department of Medicine, Medical College of Wisconsin
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16
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Derivative-free optimization of combinatorial problems – A case study in colorectal cancer screening. Comput Chem Eng 2021. [DOI: 10.1016/j.compchemeng.2020.107193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Ishibashi F, Fukushima K, Kobayashi K, Kawakami T, Tanaka R, Kato J, Sato A, Konda K, Sugihara K, Baba S. Individual feedback and monitoring of endoscopist performance improves the adenoma detection rate in screening colonoscopy: a prospective case-control study. Surg Endosc 2020; 35:2566-2575. [PMID: 32468263 DOI: 10.1007/s00464-020-07672-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Previous reports have suggested that a longer withdrawal time (WT) during colonoscopy led to an improved adenoma detection rate (ADR); however, there are few controlled studies that substantiated monitoring WT as an educational method. We aimed to validate a feedback and monitoring system to improve the ADR in screening colonoscopy in a prospective case-control setting. METHODS After collecting data in the pre-feedback period (3.5 months), the individual performance and the average ADR and WT values of the facility were provided to 6 endoscopists in the intervention group, while 3 endoscopists were isolated as the control group during the feedback period (2 weeks). The intervention group consisted of two subgroups, the Fast and Slow WT groups, according to the results from the pre-feedback period. The endoscopists in the intervention group were instructed to be aware of their own WT in each examination during the post-feedback period (4 months). The performances of all endoscopists in the post-feedback period were analyzed and compared with those in the pre-feedback period. RESULTS Among the initial analyses, the correlation analysis and multivariate analysis revealed that WT was an independent predictor for the ADR (P = 0.0101). After providing individual performance feedback and instruction regarding real-time WT monitoring, the WT was significantly prolonged in the Fast WT group (P = 0.0346) but did not change in the Slow WT and control groups. In addition, the ADR of the Fast WT group significantly improved after the intervention (P = 0.024), whereas the ADR of the Slow WT and control groups did not change. CONCLUSION Providing individual feedback on ADR and WT and monitoring WT helped improve the endoscopists' ADRs.
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Affiliation(s)
- Fumiaki Ishibashi
- Koganei Tsurukame Clinic, Endoscopy Center, 6-14-28-3F, Honcho, Koganei-shi, Tokyo, 184-0004, Japan. .,Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan. .,Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Keita Fukushima
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,Mirraza Shinjuku Tsurukame Clinic, 3-36-10, Shinjuku, Shinjuku-ku, Tokyo, 160-0022, Japan
| | - Konomi Kobayashi
- Koganei Tsurukame Clinic, Endoscopy Center, 6-14-28-3F, Honcho, Koganei-shi, Tokyo, 184-0004, Japan.,Mirraza Shinjuku Tsurukame Clinic, 3-36-10, Shinjuku, Shinjuku-ku, Tokyo, 160-0022, Japan
| | - Tomohiro Kawakami
- Koganei Tsurukame Clinic, Endoscopy Center, 6-14-28-3F, Honcho, Koganei-shi, Tokyo, 184-0004, Japan
| | - Ryu Tanaka
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan
| | - Junko Kato
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan
| | - Ayako Sato
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Kenichi Konda
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Department of Gastroenterology, Showa University Hospital, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Kazuaki Sugihara
- Koganei Tsurukame Clinic, Endoscopy Center, 6-14-28-3F, Honcho, Koganei-shi, Tokyo, 184-0004, Japan.,Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Mirraza Shinjuku Tsurukame Clinic, 3-36-10, Shinjuku, Shinjuku-ku, Tokyo, 160-0022, Japan
| | - Satoshi Baba
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Yotsuya Medical Cube, Endoscopy Center, 7-7, Nibancho, Chiyoda-ku, Tokyo, 102-0084, Japan
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18
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Grobbee EJ, van der Vlugt M, van Vuuren AJ, Stroobants AK, Mallant-Hent RC, Lansdorp-Vogelaar I, Bossuyt PMM, Kuipers EJ, Dekker E, Spaander MCW. Diagnostic Yield of One-Time Colonoscopy vs One-Time Flexible Sigmoidoscopy vs Multiple Rounds of Mailed Fecal Immunohistochemical Tests in Colorectal Cancer Screening. Clin Gastroenterol Hepatol 2020; 18:667-675.e1. [PMID: 31419575 DOI: 10.1016/j.cgh.2019.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/23/2019] [Accepted: 08/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We compared the diagnostic yields of colonoscopy, flexible sigmoidoscopy, and fecal immunochemical tests (FITs) in colorectal cancer (CRC) screening. METHODS A total of 30,007 asymptomatic persons, 50-74 years old, were invited for CRC screening in the Netherlands. Participants were assigned to groups that received 4 rounds of FIT (mailed to 15,046 participants), once-only flexible sigmoidoscopy (n = 8407), or once-only colonoscopy (n = 6600). Patients with positive results from the FIT (≥10 μg Hb/g feces) were referred for colonoscopy. Patients who underwent flexible sigmoidoscopy were referred for colonoscopy if they had a polyp of ≥10 mm; adenoma with ≥25% villous histology or high-grade dysplasia; sessile serrated adenoma; ≥3 adenomas; ≥20 hyperplastic polyps; or invasive CRC. The primary outcome was number of advanced neoplasia detected (diagnostic yield) by each test. Secondary outcomes were number of colonoscopies needed to detect advanced neoplasia and number of interval CRCs found during each primary screening test. Patients with interval CRCs were found through linkage with Netherlands Cancer Registry. Advanced neoplasia were defined as CRC, adenomas ≥ 10 mm, adenomas with high-grade dysplasia, or adenomas with a villous component of at least 25%. RESULTS The cumulative participation rate was significantly higher for FIT screening (73%) than for flexible sigmoidoscopy (31%; P < .001) or colonoscopy (24%; P < .001). The percentage of colonoscopies among invitees was higher for colonoscopy (24%) compared to FIT (13%; P < .001) or flexible sigmoidoscopy (3%; P < .001). In the intention to screen analysis, the cumulative diagnostic yield of advanced neoplasia was higher with FIT screening (4.5%; 95% CI 4.2-4.9) than with colonoscopy (2.2%; 95% CI, 1.8-2.6) or flexible sigmoidoscopy (2.3%; 95% CI, 2.0-2.7). In the as-screened analysis, the cumulative yield of advanced neoplasia was higher for endoscopic screening with colonoscopy (9.1%; 95% CI, 7.7-10.7) or flexible sigmoidoscopy (7.4%; 95% CI, 6.5-8.5) than with the FIT (6.1%; 95% CI, 5.7-6.6). All 3 screening strategies detected a similar proportion of patients with CRC. Follow-up times differed for each test (median 8.3 years for FIT and flexible sigmoidoscopy and 5.8 years for colonoscopy). Proportions of patients that developed interval CRC were 0.13% for persons with a negative result from FIT, 0.09% for persons with a negative result from flexible sigmoidoscopy, and 0.01% for persons with a negative result from colonoscopy. CONCLUSIONS Mailed multiple-round FITs detect significantly more advanced neoplasia, on a population level, compared with once-only flexible sigmoidoscopy or colonoscopy screening. Significantly fewer colonoscopies are required by individuals screened by multiple FITs. Trialregister.nl numbers: first round, NTR1096; second round and additional invitees, NTR1512; fourth round, NTR5874; COCOS trial NTR1829.
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Affiliation(s)
- Esmée J Grobbee
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Manon van der Vlugt
- Department of Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - An K Stroobants
- Clinical Chemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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19
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Zhong GC, Sun WP, Wan L, Hu JJ, Hao FB. Efficacy and cost-effectiveness of fecal immunochemical test versus colonoscopy in colorectal cancer screening: a systematic review and meta-analysis. Gastrointest Endosc 2020; 91:684-697.e15. [PMID: 31790657 DOI: 10.1016/j.gie.2019.11.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The fecal immunochemical test (FIT) and colonoscopy are the most commonly used strategies for colorectal cancer (CRC) screening worldwide. We aimed to compare their efficacy and cost-effectiveness in CRC screening in an average-risk population. METHODS PubMed, Embase, and National Health Services Economic Evaluation Database were searched. Risk ratio (RR) was used to evaluate the differences in detection rates of colorectal neoplasia between FIT and colonoscopy groups. A random-effects model was used to pool RRs. Incremental cost-effectiveness ratios (ICERs) were calculated to evaluate the cost-effectiveness of FIT versus colonoscopy. RESULTS Six randomized controlled trials and 17 cost-effectiveness studies were included. The participation rate in the FIT group was higher than that in the colonoscopy group (41.6% vs 21.9%). In the intention-to-treat analysis, FIT had a detection rate of CRC comparable with colonoscopy (RR, .73; 95% confidence interval, .37-1.42) and lower detection rates of any adenoma and advanced adenoma than 1-time colonoscopy. Most included cost-effectiveness studies showed that annual (13/15) or biennial (5/6) FIT was cost-saving (ICER < $0) or very cost-effective ($0 < ICER ≤ $25000/quality-adjusted life-year) compared with colonoscopy every 10 years. CONCLUSIONS FIT may be similar to 1-time colonoscopy in the detection rate of CRC, although it has lower detection rates of any adenoma and advanced adenoma than 1-time colonoscopy. Furthermore, annual or biennial FIT appears to be very cost-effective or cost-saving compared with colonoscopy every 10 years. These findings indicate, at least partly, that FIT is noninferior to colonoscopy in CRC screening in an average-risk population. Our findings should be treated with caution and need to be further confirmed.
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Affiliation(s)
- Guo-Chao Zhong
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei-Ping Sun
- Department of Gastrointestinal Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lun Wan
- Department of Hepatobiliary Surgery, the People's Hospital of Dazu district, Chongqing, China
| | - Jie-Jun Hu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fa-Bao Hao
- Pediatric Surgery Center, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, Shandong, China
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20
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Qualitative faecal immunochemical tests (FITs) for diagnosing colorectal cancer in patients with histories of rectal bleeding in primary care: a cohort study. Int J Colorectal Dis 2020; 35:2035-2040. [PMID: 32602056 PMCID: PMC7541370 DOI: 10.1007/s00384-020-03672-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rectal bleeding is considered an alarm symptom for colorectal cancer (CRC) but it is common and mostly caused by benign conditions. Qualitative faecal immunochemical tests (FITs) for occult blood have been used as diagnostic aids for many years in Sweden when CRC is suspected. The study aimed to evaluate the usefulness of FITs requested by primary care physicians for patients with and without histories of rectal bleeding, in the diagnosis of CRC. METHODS Results of all FITs requested in primary care for symptomatic patients in the Örebro region during 2015 were retrieved. Data on each patient's history of rectal bleeding was gathered from electronic health records. Patients diagnosed with CRC within 2 years were identified from the Swedish Cancer Register. The analysis focused on three-sample FITs, the customary FIT in Sweden. RESULTS A total of 4232 patients provided three-sample FITs. Information about the presence/absence of rectal bleeding was available for 2027 patients, of which 59 were diagnosed with CRC. For 606 patients with the presence of rectal bleeding, the FIT showed sensitivity 96.2%, specificity 60.2%, positive predictive value 9.8% (95% CI 6.1-13.4) and negative predictive value 99.7% (95% CI 99.2-100) for CRC. For 1421 patients without rectal bleeding, the corresponding figures were 100%, 73.6%, 8.3% (95% CI 5.6-10.9) and 100% (95% CI 99.6-100). CONCLUSION The diagnostic performance of a qualitative three-sample FIT provided by symptomatic patients in primary care was similar for those with and without a history of rectal bleeding. FITs seem useful for prioritising patients also with rectal bleeding for further investigation.
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Mendivil J, Appierto M, Aceituno S, Comas M, Rué M. Economic evaluations of screening strategies for the early detection of colorectal cancer in the average-risk population: A systematic literature review. PLoS One 2019; 14:e0227251. [PMID: 31891647 PMCID: PMC6938313 DOI: 10.1371/journal.pone.0227251] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022] Open
Abstract
Background Colorectal cancer (CRC) screening has proven effective in reducing CRC mortality. This study aimed to systematically review, and evaluate the reporting quality, of the economic evidence regarding CRC screening in average-risk individuals. Methods Databases searched included Medline, EMBASE, National Health Service Economic Evaluation, Database of Abstracts of Reviews of Effects, Cost-Effectiveness Analysis registry, EconLit, and Health Technology Assessment database. Eligible studies were cost-effectiveness and cost-utility analyses comparing CRC screening strategies in average-risk individuals, published in English or Spanish, between January 2012 and November 2018. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results Of 1,993 publications initially retrieved, 477 were excluded by duplicate review, 1,449 by title/abstract review, and 34 by full-text review. Finally, 33 publications were included in the qualitative synthesis. Most studies were conducted in Europe (36,4%), followed by United States (24,2%) and Asia (24,2%). The main screening modalities considered were fecal immunochemical tests (70%), colonoscopy (67%), guaiac fecal occult blood test (42%) and flexible sigmoidoscopy (30%). In most studies, CRC screening was deemed cost-effective compared to no screening. Sensitivity analyses indicated that cost of CRC screening tests, adherence to screening, screening test sensitivity, and cost of CRC treatment had the greatest impact on cost-effectiveness results across studies. The majority of studies (73%) adequately reported at least 50% of the items included in the CHEERS checklist. Least well reported items included setting, study perspective, discount rate, model choice, and methods to identify effectiveness data or to estimate resource use and costs. Conclusions CRC screening is an efficient alternative to no screening. Nevertheless, it is not possible to conclude which strategy should be preferred for population-based screening programs. Although we observed an overall good adherence to CHEERS recommendations, there is still room for improvement in economic evaluations reporting in this field.
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Affiliation(s)
- Joan Mendivil
- Outcomes Research and Epidemiology, Shire International GmbH, a Takeda Company, Zug, Switzerland
- * E-mail:
| | | | - Susana Aceituno
- Health Economics department, Outcomes’ 10 SLU, Castellon, CS, Spain
| | - Mercè Comas
- Epidemiology and Evaluation Department, IMIM (Hospital del Mar Medical Research Institute); Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
| | - Montserrat Rué
- Departament of Basic Medical Sciences, Universitat de Lleida, Lleida, Spain
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Pereira C, Areia M, Dinis-Ribeiro M. Cost-utility analysis of genetic polymorphism universal screening in colorectal cancer prevention by detection of high-risk individuals. Dig Liver Dis 2019; 51:1731-1737. [PMID: 31422007 DOI: 10.1016/j.dld.2019.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 06/02/2019] [Accepted: 07/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the past 15 years numerous studies have been published on the involvement of low-penetrance susceptibility genes on the risk for developing colorectal cancer (CRC). AIM To perform an economic analysis of blood genetic testing in CRC screening in a population-based nationwide setting using polymorphisms in prostaglandin E2 pathway genes as proof of concept. METHODS A cost-utility analysis was performed from a societal perspective in Portugal comparing two strategies: blood genetic testing by the age of 40 versus no genetic screening under different assumptions of the cost of genetic testing (€10 and €30) and expected risk (1.5 to 5-fold). The adopted threshold was set at €44,870 (USD 50,000). The primary outcome was the incremental cost-effectiveness ratio (ICER) for a base case scenario. RESULTS Polymorphism genotyping provided cost-utility only under the assumption of a 5-fold increased risk in the general population, providing ICERs of €44,356 and €30,389 for €30 and €10 tests, respectively. CONCLUSION Blood genetic screening for colorectal cancer has cost-utility only under specific assumptions of increased CRC risk and conservative cost estimates. Future studies should focus on defining genetic profiles because single-gene approaches are very unlikely to be cost-effective considering their modest predictive value.
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Affiliation(s)
- Carina Pereira
- CINTESIS - Centre for Health Technology and Services Research, University of Porto, Rua Dr Plácido da Costa, 4200-450, Porto, Portugal; Molecular Oncology and Viral Pathology Group, IPO-Porto Research Centre, Portuguese Oncology Institute of Porto, Rua Dr Bernardino de Almeida, 4200-072, Porto, Portugal.
| | - Miguel Areia
- CINTESIS - Centre for Health Technology and Services Research, University of Porto, Rua Dr Plácido da Costa, 4200-450, Porto, Portugal; Gastroenterology Department, Portuguese Institute of Oncology, Av. Bissaya Barreto, nº 98, 3000-075, Coimbra, Portugal
| | - Mário Dinis-Ribeiro
- CINTESIS - Centre for Health Technology and Services Research, University of Porto, Rua Dr Plácido da Costa, 4200-450, Porto, Portugal; Gastroenterology Department, Portuguese Institute of Oncology, Rua Dr Bernardino de Almeida, 4200-072, Porto, Portugal
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Ran T, Cheng CY, Misselwitz B, Brenner H, Ubels J, Schlander M. Cost-Effectiveness of Colorectal Cancer Screening Strategies-A Systematic Review. Clin Gastroenterol Hepatol 2019; 17:1969-1981.e15. [PMID: 30659991 DOI: 10.1016/j.cgh.2019.01.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Widespread screening for colorectal cancer (CRC) has reduced its incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide up-to-date evidence of the cost effectiveness of CRC screening strategies by answering 3 research questions. METHODS We searched PubMed, National Institute for Health Research Economic Evaluation Database, Social Sciences Citation Index (via the Web of Science), EconLit (American Economic Association) and 3 supplemental databases for original articles published in English from January 2010 through December 2017. All monetary values were converted to US dollars (year 2016). For all research questions, we extracted, or calculated (if necessary), per-person costs and life years (LYs) and/or quality-adjusted LYs, as well as the incremental costs per LY gained or quality-adjusted LY gained compared with the baseline strategy. A cost-saving strategy was defined as one that was less costly and equally or more effective than the baseline strategy. The net monetary benefit approach was used to answer research question 2. RESULTS Our review comprised 33 studies (17 from Europe, 11 from North America, 4 from Asia, and 1 from Australia). Annual and biennial guaiac-based fecal occult blood tests, annual and biennial fecal immunochemical tests, colonoscopy every 10 years, and flexible sigmoidoscopy every 5 years were cost effective (even cost saving in most US models) compared to no screening. In addition, colonoscopy every 10 years was less costly and/or more effective than other common strategies in the United States. Newer strategies such as computed tomographic colonography, every 5 or 10 years, was cost effective compared with no screening. CONCLUSIONS In an updated review, we found that common CRC screening strategies and computed tomographic colonography continued to be cost effective compared to no screening. There were discrepancies among studies from different regions, which could be associated with the model types or model assumptions.
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Affiliation(s)
- Tao Ran
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany.
| | - Chih-Yuan Cheng
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany; Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Benjamin Misselwitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Jasper Ubels
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany; Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Benitez Majano S, Di Girolamo C, Rachet B, Maringe C, Guren MG, Glimelius B, Iversen LH, Schnell EA, Lundqvist K, Christensen J, Morris M, Coleman MP, Walters S. Surgical treatment and survival from colorectal cancer in Denmark, England, Norway, and Sweden: a population-based study. Lancet Oncol 2019; 20:74-87. [PMID: 30545752 PMCID: PMC6318222 DOI: 10.1016/s1470-2045(18)30646-6] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/10/2018] [Accepted: 08/20/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Survival from colorectal cancer has been shown to be lower in Denmark and England than in comparable high-income countries. We used data from national colorectal cancer registries to assess whether differences in the proportion of patients receiving resectional surgery could contribute to international differences in colorectal cancer survival. METHODS In this population-based study, we collected data from all patients aged 18-99 years diagnosed with primary, invasive, colorectal adenocarcinoma from Jan 1, 2010, to Dec 31, 2012, in Denmark, England, Norway, and Sweden, from national colorectal cancer registries. We estimated age-standardised net survival using multivariable modelling, and we compared the proportion of patients receiving resectional surgery by stage and age. We used logistic regression to predict the resectional surgery status patients would have had if they had been treated as in the best performing country, given their individual characteristics. FINDINGS We extracted registry data for 139 457 adult patients with invasive colorectal adenocarcinoma: 12 958 patients in Denmark, 97 466 in England, 11 450 in Norway, and 17 583 in Sweden. 3-year colon cancer survival was lower in England (63·9%, 95% CI 63·5-64·3) and Denmark (65·7%, 64·7-66·8) than in Norway (69·5%, 68·4-70·5) and Sweden (72·1%, 71·2-73·0). Rectal cancer survival was lower in England (69·7%, 69·1-70·3) than in the other three countries (Denmark 72·5%, 71·1-74·0; Sweden 74·1%, 72·7-75·4; and Norway 75·0%, 73·1-76·8). We found no significant differences in survival for patients with stage I disease in any of the four countries. 3-year survival after stage II or III rectal cancer and stage IV colon cancer was consistently lower in England (stage II rectal cancer 86·4%, 95% CI 85·0-87·6; stage III rectal cancer 75·5%, 74·2-76·7; and stage IV colon cancer 20·5%, 19·9-21·1) than in Norway (94·1%, 91·5-96·0; 83·4%, 80·1-86·1; and 33·0%, 31·0-35·1) and Sweden (92·9%, 90·8-94·6; 80·6%, 78·2-82·7; and 23·7%, 22·0-25·3). 3-year survival after stage II rectal cancer and stage IV colon cancer was also lower in England than in Denmark (stage II rectal cancer 91·2%, 88·8-93·1; and stage IV colon cancer 23·5%, 21·9-25·1). The total proportion of patients treated with resectional surgery ranged from 47 803 (68·4%) of 69 867 patients in England to 9582 (81·3%) of 11 786 in Sweden for colon cancer, and from 16 544 (59·9%) of 27 599 in England to 4106 (70·8%) of 5797 in Sweden for rectal cancer. This range was widest for patients older than 75 years (colon cancer 19 078 [59·7%] of 31 946 patients in England to 4429 [80·9%] of 5474 in Sweden; rectal cancer 4663 [45·7%] of 10 195 in England to 1342 [61·9%] of 2169 in Sweden), and the proportion of patients treated with resectional surgery was consistently lowest in England. The age gradient of the decline in the proportion of patients treated with resectional surgery was steeper in England than in the other three countries in all stage categories. In the hypothetical scenario where all patients were treated as in Sweden, given their age, sex, and disease stage, the largest increase in resectional surgery would be for patients with stage III rectal cancer in England (increasing from 70·3% to 88·2%). INTERPRETATION Survival from colon cancer and rectal cancer in England and colon cancer in Denmark was lower than in Norway and Sweden. Survival paralleled the relative provision of resectional surgery in these countries. Differences in patient selection for surgery, especially in patients older than 75 years or individuals with advanced disease, might partly explain these differences in international colorectal cancer survival. FUNDING Early Diagnosis Policy Research Grant from Cancer Research UK (C7923/A18348).
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Affiliation(s)
- Sara Benitez Majano
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Chiara Di Girolamo
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Bernard Rachet
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Camille Maringe
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Marianne Grønlie Guren
- Department of Oncology and KG Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Oslo, Norwa
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Lene Hjerrild Iversen
- Department of Surgery, Aarhus University Hospital, and Danish Colorectal Cancer Group, Aarhus, Denmark
| | | | - Kristina Lundqvist
- Department of Radiation Sciences, Oncology, Umeå University, and Regionalt Cancercentrum Norr, Umeå, Sweden
| | - Jane Christensen
- Cancer Control, Documentation and Quality, Danish Cancer Society, Copenhagen, Denmark
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Michel P Coleman
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Walters
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Mantovani A, Dauriz M, Byrne CD, Lonardo A, Zoppini G, Bonora E, Targher G. Association between nonalcoholic fatty liver disease and colorectal tumours in asymptomatic adults undergoing screening colonoscopy: a systematic review and meta-analysis. Metabolism 2018; 87:1-12. [PMID: 29935236 DOI: 10.1016/j.metabol.2018.06.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/13/2018] [Accepted: 06/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is currently uncertain whether non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of colorectal tumours. We performed a meta-analysis of relevant observational studies to quantify the magnitude of the association between NAFLD and risk of colorectal adenomas and cancer. METHODS We searched PubMed, Scopus and Web of Science from January 2000 to November 2017 using pre-defined keywords to identify observational studies of asymptomatic adults undergoing screening colonoscopy, in which NAFLD was diagnosed by imaging or histology. Data from selected studies were extracted and meta-analysis was performed using random-effects modelling. RESULTS Eleven observational studies (8 cross-sectional and 3 longitudinal) with aggregate data on 91,124 asymptomatic adults (32.1% with NAFLD) of predominantly Asian descent accounting for a total of 14,911 colorectal adenomas and 1684 cancers were included in the final analysis. NAFLD was associated with an increased risk of prevalent colorectal adenomas (n = 7 studies using liver imaging techniques; random-effects odds ratio [OR] 1.28, 95% CI 1.11-1.48; I2 = 82.9% or n = 1 study using liver biopsy; random-effects OR 1.61, 95% CI 0.90-2.89) and cancer (n = 4 studies using liver imaging techniques; random-effects OR 1.56, 95% CI 1.25-1.94; I2 = 65.6% or n = 1 study using liver biopsy; random-effects OR 3.04, 95% CI 1.29-7.18). NAFLD was also associated with an increased risk of incident colorectal adenomas (n = 3 studies; random-effects hazard ratio [HR] 1.42, 95% CI 1.18-1.72; I2 = 0%) and cancer (n = 1 study; random-effects HR 3.08, 95% CI 1.02-9.03). These risks were independent of age, sex, smoking, body mass index and diabetes (or metabolic syndrome). Sensitivity analyses did not alter these findings. Funnel plot and Egger's test did not reveal significant publication bias. CONCLUSIONS This meta-analysis of observational studies (involving asymptomatic individuals of predominantly Asian descent undergoing screening colonoscopy) suggests that NAFLD (detected by imaging or biopsy) is independently associated with a moderately increased prevalence and incidence of colorectal adenomas and cancer. However, the observational design of the studies does not allow for proving causality, and the possibility of residual confounding by some unmeasured factors cannot be ruled out. More prospective studies, particularly in European and American individuals, and mechanistic studies are required to better understand the association between NAFLD and colonic carcinogenesis.
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Affiliation(s)
- Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Marco Dauriz
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Christopher D Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, UK; Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton, Southampton General Hospital, Tremona Road, Southampton, UK
| | - Amedeo Lonardo
- Department of Internal Medicine and Metabolic Diseases, Nuovo Ospedale Sant'Agostino Estense di Baggiovara, Modena, Italy
| | - Giacomo Zoppini
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Enzo Bonora
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.
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26
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Areia M, Fuccio L, Hassan C, Dekker E, Dias-Pereira A, Dinis-Ribeiro M. Cost-utility analysis of colonoscopy or faecal immunochemical test for population-based organised colorectal cancer screening. United European Gastroenterol J 2018; 7:105-113. [PMID: 30788122 DOI: 10.1177/2050640618803196] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/27/2018] [Indexed: 12/11/2022] Open
Abstract
Background Organised programmes for colorectal cancer screening demand a high burden of medical and economic resources. The preferred methods are the faecal immunochemical test and primary colonoscopy. Objective The purpose of this study was to perform an economic analysis and comparison between these tests in Europe. Methods We used a Markov cost-utility analysis from a societal perspective comparing biennial faecal immunochemical test or colonoscopy every 10 years screening versus non-screening in Portugal. The population was screened, aged from 50-74 years, and efficacy was evaluated in quality-adjusted life years. For the base-case scenario, the faecal immunochemical test cost was €3 with 50% acceptance and colonoscopy cost was €397 with 38% acceptance. The threshold was set at €39,760/quality-adjusted life years and the primary outcome was the incremental cost-effectiveness ratio. Results Screening by biennial faecal immunochemical test and primary colonoscopy every 10 years resulted in incremental utilities of 0.00151 quality-adjusted life years and 0.00185 quality-adjusted life years at additional costs of €4 and €191, respectively. The faecal immunochemical test was the most cost-effective option providing an incremental cost-effectiveness ratio of €2694/quality-adjusted life years versus €103,633/quality-adjusted life years for colonoscopy. Colonoscopy capacity would have to increase 1.3% for a faecal immunochemical test programme or 31% for colonoscopy. Conclusion Biennial faecal immunochemical test screening is better than colonoscopy as it is cost-effective, allows more individuals to get screened, and provides a more rational use of the endoscopic capacity available.
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Affiliation(s)
- Miguel Areia
- Center for Health Technology and Services Research (CINTESIS), University of Porto (FMUP), Porto, Portugal.,Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - António Dias-Pereira
- Gastroenterology Department, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Mário Dinis-Ribeiro
- Center for Health Technology and Services Research (CINTESIS), University of Porto (FMUP), Porto, Portugal.,Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
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Nielson CM, Petrik AF, Jacob L, Vollmer WM, Keast EM, Schneider JL, Rivelli JS, Kapka TJ, Meenan RT, Mummadi RR, Green BB, Coronado GD. Positive predictive values of fecal immunochemical tests used in the STOP CRC pragmatic trial. Cancer Med 2018; 7:4781-4790. [PMID: 30101513 PMCID: PMC6144161 DOI: 10.1002/cam4.1727] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/06/2018] [Accepted: 07/18/2018] [Indexed: 02/06/2023] Open
Abstract
Annual fecal immunochemical testing (FIT) is cost-effective for colorectal cancer (CRC) screening. However, FIT positivity rates and positive predictive value (PPV) can vary substantially, with false-positive (FP) results adding to colonoscopy burden without improving cancer detection. Our objective was to describe FIT PPV and the factors associated with FP results among patients undergoing CRC screening. In an ongoing pragmatic clinical trial of mailed-FIT outreach, clinics delivered one of three FIT brands (InSure, OC-Micro, and Hemosure). Patients who had a positive FIT result and a follow-up colonoscopy were included in this analysis (N = 1130). Patients' demographic and medical histories were abstracted from electronic health records (EHR). Associations with a FP result (ie, a positive FIT result with no evidence of advanced neoplasia during follow-up colonoscopy) were evaluated for FIT brand and patient factors using mixed-effects multivariable logistic regression. The mean proportion of FIT-positive results ranged from 8% in centers using the OC-Micro test to 21% for Hemosure. PPVs for advanced neoplasia were 0.30 to 0.17, respectively (P for χ2 = 0.08). In multivariable-adjusted models, use of Hemosure was associated with greater odds of a FP result than OC-Micro (OR = 2.00, 95% CI: 0.47-8.56) or InSure (OR = 1.72, 95% CI: 0.44-6.68). However, only female sex (OR = 1.58, 95% CI: 1.19-2.10) and history of a colorectal condition (OR = 2.17, 95% CI: 1.13-4.15) were significantly associated with FP. In conclusion, FIT positivity varied by brand, and FP results differed by patient factors available through the EHR. These results can be used to minimize the frequency of FP results, reducing patient distress and colonoscopy burden.
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Affiliation(s)
| | | | | | | | - Erin M. Keast
- Kaiser Permanente Center for Health ResearchPortlandOregon
| | | | | | - Tanya J. Kapka
- Kaiser Permanente Center for Health ResearchPortlandOregon
| | | | | | - Beverly B. Green
- Kaiser Permanente Washington Health Research InstituteSeattleWashington
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Iragorri N, Spackman E. Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis. Public Health Rev 2018; 39:17. [PMID: 30009081 PMCID: PMC6043991 DOI: 10.1186/s40985-018-0093-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/04/2018] [Indexed: 12/29/2022] Open
Abstract
Background Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools. Objective This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them. Methods A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized. Results Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early. Conclusions To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary.
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Affiliation(s)
- Nicolas Iragorri
- 1Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada.,2Health Technology Assessment Unit, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
| | - Eldon Spackman
- 1Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada.,2Health Technology Assessment Unit, University of Calgary, Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
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Abstract
PURPOSE Lynch syndrome (LS) is associated with a high risk of colorectal cancer (CRC). The aim of this study was to assess the cumulative risk for the development of colorectal adenomas or carcinomas in a LS CRC surveillance program and to audit the quality of the endoscopic procedures. METHODS We evaluated 147 asymptomatic LS mutation carriers, without previous CRC, in a surveillance program with colonoscopy every 12-18 months, between 2005 and 2016. Data was obtained by retrospective review of colonoscopy reports and hospital clinical files. The main outcome was assessed using Kaplan-Meier curves. Logistic regression was used to study the risk of developing adenomas. RESULTS Patients were under surveillance for 1092 observation years (mean, 7.7 years/patient). Most exams presented adequate bowel preparation (83.5%) and 99.2% achieved cecal intubation. The estimated risk for adenomas at age 60 was 75.6% in men (95%CI, 60.5-88.3) and 65.5% in women (95%CI, 50.8-79.7). Male gender (OR 2.4; 95%CI, 1.2-4.9; p = 0.018) and age at start of surveillance > 40 years (OR 3.7; 95%CI, 1.8-7.7; p < 0.001) were independent risk factors for adenoma detection. CRC was diagnosed in 11 patients with an estimated cumulative risk at age 60 of 18.4% (95%CI, 9.2-34.8%); 72.7% of CRC were classified as stage I; no patient died from CRC. CONCLUSION A colonoscopic surveillance program in LS patients allowed the detection of adenomas in a large group of mutation carriers and diagnosis of early-stage carcinomas. Our findings may help other teams to adopt similar strategies or to refer patients early to specialized centers.
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