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Takayama Y, Tsukamoto S, Kudose Y, Takamizawa Y, Moritani K, Esaki M, Kanemitsu Y, Igarashi A. Cost-effectiveness of surveillance intervals after curative resection of colorectal cancer. Jpn J Clin Oncol 2024; 54:637-646. [PMID: 38376792 DOI: 10.1093/jjco/hyae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/25/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Major guidelines consistently recommend 5 years of postoperative surveillance for patients with colorectal cancer. However, they differ in their recommendations for examination intervals and whether they should vary according to disease stage. Furthermore, there are no reports on the cost-effectiveness of the different surveillance schedules. The objective of this study is to identify the most cost-effective surveillance intervals after curative resection of colorectal cancer. METHODS A total of 3701 patients who underwent curative surgery for colorectal cancer at the National Cancer Center Hospital were included. A cost-effectiveness analysis was conducted for the five surveillance strategies with reference to the guidelines. Expected medical costs and quality-adjusted life years after colorectal cancer resection were calculated using a state-transition model by Monte Carlo simulation. The incremental cost-effectiveness ratio per quality-adjusted life years gained was calculated for each strategy, with a maximum acceptable value of 43 500-52 200 USD (5-6 million JPY). RESULTS Stages I, II and III included 1316, 1082 and 1303 patients, respectively, with 45, 140 and 338 relapsed cases. For patients with stage I disease, strategy 4 (incremental cost-effectiveness ratio $26 555/quality-adjusted life year) was considered to be the most cost-effective, while strategies 3 ($83 071/quality-adjusted life year) and 2 ($289 642/quality-adjusted life year) exceeded the threshold value. In stages II and III, the incremental cost-effectiveness ratio for strategy 3 was the most cost-effective option, with an incremental cost-effectiveness ratio of $18 358-22 230/quality-adjusted life year. CONCLUSIONS In stage I, the cost-effectiveness of intensive surveillance is very poor and strategy 4 is the most cost-effective. Strategy 3 is the most cost-effective in stages II and III.
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Affiliation(s)
- Yuji Takayama
- Department of Colorectal Surgery, National Cancer Center, Tokyo, Japan
| | | | - Yozo Kudose
- Department of Colorectal Surgery, National Cancer Center, Tokyo, Japan
| | | | - Konosuke Moritani
- Department of Colorectal Surgery, National Cancer Center, Tokyo, Japan
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center, Tokyo, Japan
| | | | - Ataru Igarashi
- Department of Health Economics and Outcomes Research, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
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2
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Pimentel-Nunes P, Libânio D, Bastiaansen BAJ, Bhandari P, Bisschops R, Bourke MJ, Esposito G, Lemmers A, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, van Hooft JE, Deprez PH, Dinis-Ribeiro M. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2022; 54:591-622. [PMID: 35523224 DOI: 10.1055/a-1811-7025] [Citation(s) in RCA: 228] [Impact Index Per Article: 114.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD.
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Affiliation(s)
- Pedro Pimentel-Nunes
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- Department of Surgery and Physiology, Porto Faculty of Medicine, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Center, The Netherlands
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia and Western Clinical School, University of Sydney, Sydney, Australia
| | - Gianluca Esposito
- Department of Medical-Surgical Sciences and Translational Medicine, Sant' Andrea Hospital, Sapienza University of Rome, Italy
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Bayern, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
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Kuntz KM, Popp J, Beck JR, Zauber AG, Weinberg DS. Cost-effectiveness of surveillance with CT colonography after resection of colorectal cancer. BMJ Open Gastroenterol 2020; 7:e000450. [PMID: 32933928 PMCID: PMC7493100 DOI: 10.1136/bmjgast-2020-000450] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Surveillance following colorectal cancer (CRC) resection uses optical colonoscopy (OC) to detect intraluminal disease and CT to detect extracolonic recurrence. CT colonography (CTC) might be an efficient use of resources in this situation because it allows for intraluminal and extraluminal evaluations with one test. DESIGN We developed a simulation model to compare lifetime costs and benefits for a cohort of patients with resected CRC. Standard of care involved annual CT for 3 years and OC for years 1, 4 and every 5 years thereafter. For the CTC-based strategy, we replace CT+OC at year 1 with CTC. Patients with lesions greater than 6 mm detected by CTC underwent OC. Detection of an adenoma 10 mm or larger was followed by OC at 1 year, then every 3 years thereafter. Test characteristics and costs for CTC were derived from a clinical study. Medicare costs were used for cancer care costs as well as alternative test costs. We discounted costs and effects at 3% per year. RESULTS For persons with resected stage III CRC, the standard-of-care strategy was more costly (US$293) and effective (2.6 averted CRC cases and 1.1 averted cancer deaths per 1000) than the CTC-based strategy, with an incremental cost-effectiveness ratio of US$55 500 per quality-adjusted life-year gained. Our analysis was most sensitive to the sensitivity of CTC for detecting polyps 10 mm or larger and assumptions about disease progression. CONCLUSION In a simulation model, we found that replacing the standard-of-care approach to postdiagnostic surveillance with a CTC-based strategy is not an efficient use of resources in most situations.
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Affiliation(s)
- Karen M Kuntz
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jonah Popp
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - J Robert Beck
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David S Weinberg
- Department of Medicine, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
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Rutter MD, East J, Rees CJ, Cripps N, Docherty J, Dolwani S, Kaye PV, Monahan KJ, Novelli MR, Plumb A, Saunders BP, Thomas-Gibson S, Tolan DJM, Whyte S, Bonnington S, Scope A, Wong R, Hibbert B, Marsh J, Moores B, Cross A, Sharp L. British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England post-polypectomy and post-colorectal cancer resection surveillance guidelines. Gut 2020; 69:201-223. [PMID: 31776230 PMCID: PMC6984062 DOI: 10.1136/gutjnl-2019-319858] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022]
Abstract
These consensus guidelines were jointly commissioned by the British Society of Gastroenterology (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Public Health England (PHE). They provide an evidence-based framework for the use of surveillance colonoscopy and non-colonoscopic colorectal imaging in people aged 18 years and over. They are the first guidelines that take into account the introduction of national bowel cancer screening. For the first time, they also incorporate surveillance of patients following resection of either adenomatous or serrated polyps and also post-colorectal cancer resection. They are primarily aimed at healthcare professionals, and aim to address:Which patients should commence surveillance post-polypectomy and post-cancer resection?What is the appropriate surveillance interval?When can surveillance be stopped? two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument provided a methodological framework for the guidelines. The BSG's guideline development process was used, which is National Institute for Health and Care Excellence (NICE) compliant.two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps The key recommendations are that the high-risk criteria for future colorectal cancer (CRC) following polypectomy comprise either:two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps This cohort should undergo a one-off surveillance colonoscopy at 3 years. Post-CRC resection patients should undergo a 1 year clearance colonoscopy, then a surveillance colonoscopy after 3 more years.
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Affiliation(s)
- Matthew D Rutter
- Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - James East
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Colin J Rees
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
- Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, UK
| | - Neil Cripps
- Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | | | - Sunil Dolwani
- Gastroenterology, Cardiff and Vale NHS Trust, Cardiff, UK
| | - Philip V Kaye
- Histopathology, Nottingham University Hospitals, Nottingham, UK
| | - Kevin J Monahan
- Family History of Bowel Cancer Clinic, West Middlesex University Hospital, London, UK
- Imperial College, London, UK
| | | | | | | | | | - Damian J M Tolan
- Clinical Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sophie Whyte
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | | | - Amanda Cross
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine of Imperial College, Imperial College London, London, UK
| | - Linda Sharp
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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5
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Ramphal W, Boeding JRE, Schreinemakers JMJ, Gobardhan PD, Rutten HJT, Crolla RMPH. Colonoscopy Surveillance After Colorectal Cancer: the Optimal Interval for Follow-Up. J Gastrointest Cancer 2019; 51:469-477. [PMID: 31155695 DOI: 10.1007/s12029-019-00254-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Patients who have undergone curative surgery for colorectal cancer are at risk of developing a metachronous colorectal tumour or anastomotic recurrence. The aim of this study was to determine the incidence of recurrent colorectal cancer in a cohort of patients who participated in a colonoscopy surveillance programme. METHODS This single-centre retrospective observational cohort study included patients who underwent curative surgery for colorectal cancer between 2005 and 2015. All reports of postoperative colonoscopies were retrieved to calculate the incidence rates of recurrence and metachronous colorectal cancer. RESULTS Of 2420 patients, 1644 (67.9%) underwent at least one postoperative colonoscopy and 776 (32.1%) did not. In 1087 patients, colonoscopy was performed in the first 18 months after surgery, which detected 34 (3.1%) instances of metachronous colorectal tumours or anastomotic recurrence. Thirty-three additional patients were also diagnosed with recurrent colorectal cancer, but the tumours were detected by other diagnostic modalities or detected perioperatively, rather than by colonoscopy. CONCLUSIONS Patients with a history of colorectal cancer have an increased risk for a second colorectal tumour. Therefore, we recommend a colonoscopic surveillance programme with the first colonoscopy performed 1 year after curative surgery, which is in accordance with national guidelines.
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Affiliation(s)
- Winesh Ramphal
- Department of Surgery, Amphia Hospital Breda, Molengracht 21, 4818 CK, Breda, The Netherlands.
| | - Jeske R E Boeding
- Department of Surgery, Amphia Hospital Breda, Molengracht 21, 4818 CK, Breda, The Netherlands
| | | | - Paul D Gobardhan
- Department of Surgery, Amphia Hospital Breda, Molengracht 21, 4818 CK, Breda, The Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - Rogier M P H Crolla
- Department of Surgery, Amphia Hospital Breda, Molengracht 21, 4818 CK, Breda, The Netherlands
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Pioche M, Walter T. Endoscopic removal of colorectal T1 cancers: Why is a 1-year follow-up recommended by ESGE when resection is R0 and curative? Endosc Int Open 2019; 7:E816-E817. [PMID: 31198845 PMCID: PMC6561767 DOI: 10.1055/a-0900-3878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Mathieu Pioche
- Hepatogastroenterology Division, Edouard Herriot Hospital, Lyon, France,Corresponding author Mathieu Pioche, MD, PhD Service de gastro-entérologie et d’endoscopie digestivePavillon LHôpital Edouard Herriot5 place d’Arsonval69437 LyonFrance+33472110147
| | - Thomas Walter
- Digestive Oncology Division, Edouard Herriot Hospital, Lyon, France
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Mangas-Sanjuan C, Jover R, Cubiella J, Marzo-Castillejo M, Balaguer F, Bessa X, Bujanda L, Bustamante M, Castells A, Diaz-Tasende J, Díez-Redondo P, Herráiz M, Mascort-Roca JJ, Pellisé M, Quintero E. Vigilancia tras resección de pólipos de colon y de cáncer colorrectal. Actualización 2018. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:188-201. [PMID: 30621911 DOI: 10.1016/j.gastrohep.2018.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 02/07/2023]
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Liu SL, Cheung WY. Role of surveillance imaging and endoscopy in colorectal cancer follow-up: Quality over quantity? World J Gastroenterol 2019; 25:59-68. [PMID: 30643358 PMCID: PMC6328961 DOI: 10.3748/wjg.v25.i1.59] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/25/2018] [Accepted: 12/06/2018] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is a prevalent disease and represents a major cause of morbidity and mortality in the developed world. Intensive post-treatment surveillance is routinely recommended by major expert groups for early stage (II and III) CRC survivors because previous meta-analyses showed a modest, but significant survival benefit. This practice has been recently challenged based on data emerging from several large phase III randomized trials that demonstrated a lack of survival benefit from intensive surveillance strategies. In addition, findings from cost-effectiveness analyses of such an approach are inconsistent. Data on real-world practice, specifically adherence to these follow-up guidelines, are also limited. The debate is especially controversial in resected stage IV patients where there are currently no clear guidelines for follow-up. In an era of personalized medicine, there may be a shift towards a more risk-adapted approach to better define the optimal follow-up strategy. In this article, we review the evidence and highlight the role of surveillance in CRC survivors.
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Affiliation(s)
- Shiru L Liu
- Department of Medical Oncology, University of British Columbia, Vancouver, BC V5Z 4E6, Canada
| | - Winson Y Cheung
- Department of Oncology, University of Calgary, Calgary, Alberta T2N 4N2, Canada
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Sekiguchi M, Matsuda T, Saito Y. Surveillance after endoscopic and surgical resection of colorectal cancer. Best Pract Res Clin Gastroenterol 2016; 30:959-970. [PMID: 27938790 DOI: 10.1016/j.bpg.2016.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 08/05/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
With the increase in colorectal cancer burden, surveillance following endoscopic and surgical resection is an essential issue. The aim of surveillance programs is improvement of patient survival by early detection of residual tumor tissue or local recurrence, metachronous colorectal tumors, and metastases. Appropriate surveillance should be determined according to this risk of factors. In current guidelines, only surveillance colonoscopy is recommended after endoscopic resection of polyps with high-grade dysplasia, whereas intensive, multimodality surveillance using colonoscopy, radiological imaging and tumor marker measurements is recommended following surgical resection of invasive colorectal cancer. Detailed recommendations, including the timing of surveillance, are described based on high-quality evidence. However, there are still many unresolved issues for which more high-quality evidence is required.
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Affiliation(s)
- Masau Sekiguchi
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan; Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Takahisa Matsuda
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan; Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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10
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Kisiel JB, Konijeti GG, Piscitello AJ, Chandra T, Goss TF, Ahlquist DA, Farraye FA, Ananthakrishnan AN. Stool DNA Analysis is Cost-Effective for Colorectal Cancer Surveillance in Patients With Ulcerative Colitis. Clin Gastroenterol Hepatol 2016; 14:1778-1787.e8. [PMID: 27464589 PMCID: PMC5108686 DOI: 10.1016/j.cgh.2016.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/17/2016] [Accepted: 07/10/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with chronic ulcerative colitis are at increased risk for colorectal neoplasia (CRN). Surveillance by white-light endoscopy (WLE) or chromoendoscopy may reduce risk of CRN, but these strategies are underused. Analysis of DNA from stool samples (sDNA) can detect CRN with high levels of sensitivity, but it is not clear if this approach is cost-effective. We simulated these strategies for CRN detection to determine which approach is most cost-effective. METHODS We adapted a previously published Markov model to simulate the clinical course of chronic ulcerative colitis, the incidence of cancer or dysplasia, and costs and benefits of care with 4 surveillance strategies: (1) analysis of sDNA and diagnostic chromoendoscopy for patients with positive results, (2) analysis of sDNA with diagnostic WLE for patients with positive results, (3) chromoendoscopy with targeted collection of biopsies, or (4) WLE with random collection of biopsies. Costs were based on 2014 Medicare reimbursement. The primary outcome was the incremental cost-effectiveness ratio (incremental cost/incremental difference in quality-adjusted life-years) compared with no surveillance and a willingness-to-pay threshold of $50,000. RESULTS All strategies fell below the willingness-to-pay threshold at 2-year intervals. Incremental cost-effectiveness ratios were $16,362 per quality-adjusted life-year for sDNA analysis with diagnostic chromoendoscopy; $18,643 per quality-adjusted life-year for sDNA analysis with diagnostic WLE; $23,830 per quality-adjusted life-year for chromoendoscopy alone; and $27,907 per quality-adjusted life-year for WLE alone. In sensitivity analyses, sDNA analysis with diagnostic chromoendoscopy was more cost-effective than chromoendoscopy alone, up to a cost of $1135 per sDNA test. sDNA analysis remained cost-effective at all rates of compliance; when combined with diagnostic chromoendoscopy, this approach was preferred over chromoendoscopy alone, when the specificity of the sDNA test for CRN was >65%. CONCLUSIONS Based on a Markov model, surveillance for CRN is cost-effective for patients with chronic ulcerative colitis. Analysis of sDNA with chromoendoscopies for patients with positive results was more cost-effective than chromoendoscopy or WLE alone.
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Affiliation(s)
- John B. Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester MN
| | - Gauree G. Konijeti
- Division of Gastroenterology, Scripps Clinic, La Jolla CA,Scripps Translational Science Institute, La Jolla, CA
| | | | | | | | - David A. Ahlquist
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester MN
| | - Francis A. Farraye
- Center for Digestive Disorders, Boston Medical Center, Section of Gastroenterology, Boston University School of Medicine, Boston MA
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital and Harvard Medical School, Boston MA
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11
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Erenay FS, Alagoz O, Banerjee R, Said A, Cima RR. Cost-effectiveness of alternative colonoscopy surveillance strategies to mitigate metachronous colorectal cancer incidence. Cancer 2016; 122:2560-70. [PMID: 27248907 DOI: 10.1002/cncr.30091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/21/2016] [Accepted: 04/07/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The incidence of metachronous colorectal cancer (MCRC) among colorectal cancer (CRC) survivors varies significantly, and the optimal colonoscopy surveillance practice for mitigating MCRC incidence is unknown. METHODS A cost-effectiveness analysis was used to compare the performances of the US Multi-Society Task Force guideline and all clinically reasonable colonoscopy surveillance strategies for 50- to 79-year-old posttreatment CRC patients with a computer simulation model. RESULTS The US guideline [(1,3,5)] recommends the first colonoscopy 1 year after treatment, whereas the second and third colonoscopies are to be repeated at 3- and 5-year intervals. Some promising alternative cost-effective strategies were identified. In comparison with the US guideline, under various scenarios for a 20-year period, 1) reducing the surveillance interval of the guideline after the first colonoscopy by 1 year [(1,2,5)] would save up to 78 discounted life-years (LYs) and prevent 23 MCRCs per 1000 patients (incremental cost-effectiveness ratio [ICER] ≤ $23,270/LY), 2) reducing the intervals after the first and second negative colonoscopies by 1 year [(1,2,4)] would save/prevent up to 109 discounted LYs and 36 MCRCs (ICER ≤ $52,155/LY), and 3) reducing the surveillance intervals after the first and second negative colonoscopy by 1 and 2 years [(1,2,3)] would save/prevent up to 141 discounted LYs and 50 MCRCs (ICER ≤ $63,822/LY). These strategies would require up to 1100 additional colonoscopies per 1000 patients. Although the US guideline might not be cost-effective in comparison with a less intensive oncology guideline [(3,3,5); the ICER could be as high as $140,000/LY], the promising strategies would be cost-effective in comparison with such less intensive guidelines unless the cumulative MCRC incidence were very low. CONCLUSIONS The US guideline might be improved by a slight increase in the surveillance intensity at the expense of moderately increased cost. More research is warranted to explore the benefits/harms of such practices. Cancer 2016;122:2560-70. © 2016 American Cancer Society.
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Affiliation(s)
- Fatih Safa Erenay
- Department of Management Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Adnan Said
- Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, Minnesota
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12
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Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Robertson DJ, Rex DK. Colonoscopy surveillance after colorectal cancer resection: recommendations of the US multi-society task force on colorectal cancer. Gastrointest Endosc 2016; 83:489-98.e10. [PMID: 26802191 DOI: 10.1016/j.gie.2016.01.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Charles J Kahi
- Richard L. Roudebush VA Medical Center, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, Indiana.
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- Veterans Affairs Palo Alto, Palo Alto, California; Stanford University School of Medicine, Palo Alto, California
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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13
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Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Robertson DJ, Rex DK. Colonoscopy Surveillance After Colorectal Cancer Resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2016; 150:758-768.e11. [PMID: 26892199 DOI: 10.1053/j.gastro.2016.01.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The US Multi-Society Task Force has developed updated recommendations to guide health care providers with the surveillance of patients after colorectal cancer (CRC) resection with curative intent. This document is based on a critical review of the literature regarding the role of colonoscopy, flexible sigmoidoscopy, endoscopic ultrasound, fecal testing and CT colonography in this setting. The document addresses the effect of surveillance, with focus on colonoscopy, on patient survival after CRC resection, the appropriate use and timing of colonoscopy for perioperative clearing and for postoperative prevention of metachronous CRC, specific considerations for the detection of local recurrence in the case of rectal cancer, as well as the place of CT colonography and fecal tests in post-CRC surveillance.
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Affiliation(s)
- Charles J Kahi
- Richard L. Roudebush VA Medical Center, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, Indiana.
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- Veterans Affairs Palo Alto, Palo Alto, California; Stanford University School of Medicine, Palo Alto, California
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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14
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Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Robertson DJ, Rex DK. Colonoscopy Surveillance after Colorectal Cancer Resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2016; 111:337-46; quiz 347. [PMID: 26871541 DOI: 10.1038/ajg.2016.22] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/07/2015] [Indexed: 12/11/2022]
Abstract
The US Multi-Society Task Force has developed updated recommendations to guide health care providers with the surveillance of patients after colorectal cancer (CRC) resection with curative intent. This document is based on a critical review of the literature regarding the role of colonoscopy, flexible sigmoidoscopy, endoscopic ultrasound, fecal testing and CT colonography in this setting. The document addresses the effect of surveillance, with focus on colonoscopy, on patient survival after CRC resection, the appropriate use and timing of colonoscopy for perioperative clearing and for postoperative prevention of metachronous CRC, specific considerations for the detection of local recurrence in the case of rectal cancer, as well as the place of CT colonography and fecal tests in post-CRC surveillance.
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Affiliation(s)
- Charles J Kahi
- Richard L. Roudebush VA Medical Center, Indianapolis, IN.,Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington.,University of Washington School of Medicine, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- Veterans Affairs Palo Alto, Palo Alto, California.,Stanford University School of Medicine, Palo Alto, California
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont.,Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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15
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Meregaglia M, Cairns J. Economic evaluations of follow-up strategies for cancer survivors: a systematic review and quality appraisal of the literature. Expert Rev Pharmacoecon Outcomes Res 2015; 15:913-29. [PMID: 26449255 DOI: 10.1586/14737167.2015.1087316] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The aim of this study was to review and critically assess the health economics literature on post-treatment follow-up for adult cancer survivors. A systematic search was performed using PubMed, EMBASE and the Cochrane Library. The Consolidated Health Economic Evaluation Reporting Standards checklist was adopted to assess the quality of the included studies. Thirty-nine articles met the eligibility criteria. Around two thirds of the studies addressed the most common cancers (i.e., breast, colorectal, cervical and lung); 21 were based on a single clinical study, while the rest were modeling papers. All types of economic evaluations were represented other than cost-benefit analysis. The overall quality was generally high with an average proportion of 74% of checklist criteria fulfilled. The cost-effectiveness results supported the current trend towards less intensive, primary care-based and risk-adapted follow-up schemes.
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Affiliation(s)
- Michela Meregaglia
- a 1 Department of Health Services Research and Policy; Faculty of Public Health and Policy; London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place London WC1H 9SH, UK.,b 2 CeRGAS (Research Centre on Health and Social Care Management), Bocconi University, Via Roentgen 1, 20136 Milan, Italy
| | - John Cairns
- a 1 Department of Health Services Research and Policy; Faculty of Public Health and Policy; London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place London WC1H 9SH, UK
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16
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Ruggeri M, Manca A, Coretti S, Codella P, Iacopino V, Romano F, Mascia D, Orlando V, Cicchetti A. Investigating the Generalizability of Economic Evaluations Conducted in Italy: A Critical Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:709-720. [PMID: 26297100 DOI: 10.1016/j.jval.2015.03.1795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 02/27/2015] [Accepted: 03/29/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess the methodological quality of Italian health economic evaluations and their generalizability or transferability to different settings. METHODS A literature search was performed on the PubMed search engine to identify trial-based, nonexperimental prospective studies or model-based full economic evaluations carried out in Italy from 1995 to 2013. The studies were randomly assigned to four reviewers who applied a detailed checklist to assess the generalizability and quality of reporting. The review process followed a three-step blinded procedure. The reviewers who carried out the data extraction were blind as to the name of the author(s) of each study. Second, after the first review, articles were reassigned through a second blind randomization to a second reviewer. Finally, any disagreement between the first two reviewers was solved by a senior researcher. RESULTS One hundred fifty-one economic evaluations eventually met the inclusion criteria. Over time, we observed an increasing transparency in methods and a greater generalizability of results, along with a wider and more representative sample in trials and a larger adoption of transition-Markov models. However, often context-specific economic evaluations are carried out and not enough effort is made to ensure the transferability of their results to other contexts. In recent studies, cost-effectiveness analyses and the use of incremental cost-effectiveness ratio were preferred. CONCLUSIONS Despite a quite positive temporal trend, generalizability of results still appears as an unsolved question, even if some indication of improvement within Italian studies has been observed.
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Affiliation(s)
- Matteo Ruggeri
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | - Silvia Coretti
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Paola Codella
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valentina Iacopino
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Romano
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Daniele Mascia
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valentina Orlando
- Inter-departmental Research Centre of PharmacoEconomics and Drug utilization (CIRFF), Center of Pharmacoeconomics, Federico II University of Naples, Naples, Italy
| | - Americo Cicchetti
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
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17
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Young PE, Womeldorph CM, Johnson EK, Maykel JA, Brucher B, Stojadinovic A, Avital I, Nissan A, Steele SR. Early detection of colorectal cancer recurrence in patients undergoing surgery with curative intent: current status and challenges. J Cancer 2014; 5:262-71. [PMID: 24790654 PMCID: PMC3982039 DOI: 10.7150/jca.7988] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite advances in neoadjuvant and adjuvant therapy, attention to proper surgical technique, and improved pathological staging for both the primary and metastatic lesions, almost half of all colorectal cancer patients will develop recurrent disease. More concerning, this includes ~25% of patients with theoretically curable node-negative, non-metastatic Stage I and II disease. Given the annual incidence of colorectal cancer, approximately 150,000 new patients are candidates each year for follow-up surveillance. When combined with the greater population already enrolled in a surveillance protocol, this translates to a tremendous number of patients at risk for recurrence. It is therefore imperative that strategies aim for detection of recurrence as early as possible to allow initiation of treatment that may still result in cure. Yet, controversy exists regarding the optimal surveillance strategy (high-intensity vs. traditional), ideal testing regimen, and overall effectiveness. While benefits may involve earlier detection of recurrence, psychological welfare improvement, and greater overall survival, this must be weighed against the potential disadvantages including more invasive tests, higher rates of reoperation, and increased costs. In this review, we will examine the current options available and challenges surrounding colorectal cancer surveillance and early detection of recurrence.
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Affiliation(s)
- Patrick. E. Young
- 1. Department of Medicine, Division of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- 3. Department of Medicine, Uniformed Services University of Health Science, Bethesda, MD, USA
| | - Craig M. Womeldorph
- 2. Department of Medicine, Division of Gastroenterology, San Antonio Military Medical Center, San Antonio, TX, USA
- 3. Department of Medicine, Uniformed Services University of Health Science, Bethesda, MD, USA
| | - Eric K. Johnson
- 4. Department of Surgery, Madigan Army Center, Tacoma, WA, USA
| | - Justin A. Maykel
- 5. Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | | | | | | | - Aviram Nissan
- 7. Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Scott R. Steele
- 4. Department of Surgery, Madigan Army Center, Tacoma, WA, USA
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18
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Konijeti GG, Shrime MG, Ananthakrishnan AN, Chan AT. Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis. Gastrointest Endosc 2014; 79:455-65. [PMID: 24262637 PMCID: PMC4116277 DOI: 10.1016/j.gie.2013.10.026] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 10/14/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies report that the risk of colorectal cancer (CRC) among patients with ulcerative colitis (UC) may be lower than previously estimated. Although white-light endoscopy (WLE) with random biopsies is recommended for dysplasia detection in patients with UC, several studies reported increased detection of dysplasia by chromoendoscopy. OBJECTIVE To analyze the cost effectiveness of chromoendoscopy relative to WLE or no endoscopy for CRC surveillance in patients with UC. DESIGN Decision-analytic state-transition (Markov) model with Monte Carlo simulation. SETTING To simulate the clinical course of chronic UC, we estimated dysplasia and CRC incidence and progression, endoscopic test characteristics, stage-specific mortality rates, and costs from published literature and Medicare reimbursement data. PATIENTS Patients from a population-based age distribution with ulcerative colitis for ≥8 years. INTERVENTION We compared 3 different strategies at various surveillance intervals: chromoendoscopy with targeted biopsies, WLE with random biopsies, and no surveillance. The robustness of the model was assessed by using probabilistic sensitivity analysis. One-way sensitivity analyses were performed to evaluate individual variables, and 3-dimensional analysis was used to examine the effects of varying screening intervals. MAIN OUTCOME MEASUREMENTS Incremental cost-effectiveness ratio (ICER). RESULTS Chromoendoscopy was found to be more effective and less costly than WLE at all surveillance intervals. However, compared with no surveillance, chromoendoscopy was cost effective only at surveillance intervals of at least 7 years, with an ICER of $77,176. Chromoendoscopy was the most cost effective strategy at sensitivity levels >0.23 for dysplasia detection and cost <$2200, regardless of the level of sensitivity of WLE for dysplasia detection. The estimated population lifetime risk of developing CRC ranged from 2.5% (annual chromoendoscopy) to 5.9% (chromoendoscopy every 10 years). LIMITATIONS Estimates used for the model are based on best available data in the literature. CONCLUSION Chromoendoscopy is both more effective and less costly than WLE and becomes cost effective relative to no surveillance when performed at intervals of ≥7 years.
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19
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Mobley L, Kuo TM, Urato M, Boos J, Lozano-Gracia N, Anselin L. Predictors of endoscopic colorectal cancer screening over time in 11 states. Cancer Causes Control 2009; 21:445-61. [PMID: 19946738 PMCID: PMC2835730 DOI: 10.1007/s10552-009-9476-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 11/10/2009] [Indexed: 11/25/2022]
Abstract
Objectives We study a cohort of Medicare-insured men and women aged 65+ in the year 2000, who lived in 11 states covered by Surveillance, Epidemiology, and End Results (SEER) cancer registries, to better understand various predictors of endoscopic colorectal cancer (CRC) screening. Methods We use multilevel probit regression on two cross-sectional periods (2000–2002, 2003–2005) and include people diagnosed with breast cancer, CRC, or inflammatory bowel disease (IBD) and a reference sample without cancer. Results Men are not universally more likely to be screened than women, and African Americans, Native Americans, and Hispanics are not universally less likely to be screened than whites. Disparities decrease over time, suggesting that whites were first to take advantage of an expansion in Medicare benefits to cover endoscopic screening for CRC. Higher-risk persons had much higher utilization, while older persons and beneficiaries receiving financial assistance for Part B coverage had lower utilization and the gap widened over time. Conclusions Screening for CRC in our Medicare-insured sample was less than optimal, and reasons varied considerably across states. Negative managed care spillovers were observed, demonstrating that policy interventions to improve screening rates should reflect local market conditions as well as population diversity.
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Affiliation(s)
- Lee Mobley
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Durham, NC 27709-2194 USA
| | - Tzy-Mey Kuo
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Durham, NC 27709-2194 USA
| | - Matthew Urato
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Durham, NC 27709-2194 USA
| | - John Boos
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Durham, NC 27709-2194 USA
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