Cost-effectiveness in the prevention of colorectal cancer

National and subnational incidence, mortality and associated factors of colorectal cancer in China: A systematic analysis and modelling study

Background

Due to their known variation by geography and economic development, we aimed to evaluate the incidence and mortality of colorectal cancer (CRC) in China over the past decades and identify factors associated with CRC among the Chinese population to provide targeted information on disease prevention.

Methods

We conducted a systemic review and meta-analysis of epidemiolocal studies on the incidence, mortality, and associated factors of CRC among the Chinese population, extracting and synthesising data from eligible studies retrieved from seven global and Chinese databases. We pooled age-standardised incidence rates (ASIRs) and mortality rates (ASMRs) for each province, subregion, and the whole of China, and applied a joinpoint regression model and annual per cent changes (APCs) to estimate the trends of CRC incidence and mortality. We conducted random-effects meta-analyses to assess the effect estimates of identified associated risk factors.

Results

We included 493 articles; 271 provided data on CRC incidence or mortality, and 222 on associated risk factors. Overall, the ASIR of CRC in China increased from 2.75 to 19.39 (per 100 000 person-years) between 1972 and 2019 with a slowed-down growth rate (APC1 = 5.75, APC2 = 0.42), while the ASMR of CRC decreased from 12.00 to 7.95 (per 100 000 person-years) between 1974 and 2020 with a slight downward trend (APC = -0.89). We analysed 62 risk factors with synthesized data; 16 belonging to the categories of anthropometrics factors, lifestyle factors, dietary factors, personal histories and mental health conditions were graded to be associated with CRC risk among the Chinese population in the meta-analysis limited to the high-quality studies.

Conclusions

We found substantial variation of CRC burden across regions and provinces of China and identified several associated risk factors for CRC, which could help to guide the formulation of targeted disease prevention and control strategies.

Registration

PROSPERO: CRD42022346558.

Should we screen for colorectal cancer in people aged 75 and over? A systematic review - collaborative work of the French geriatric oncology society (SOFOG) and the French federation of digestive oncology (FFCD)

BACKGROUND

We have done a systematic literature review about CRC Screening over 75 years old in order to update knowledge and make recommendations.

METHODS

PUBMED database was searched in October 2021 for articles published on CRC screening in the elderly, and generated 249 articles. Further searches were made to find articles on the acceptability, efficacy, and harms of screening in this population, together with the state of international guidelines.

RESULTS

Most benefit-risk data on CRC screening in the over 75 s derived from simulation studies. Most guidelines recommend stopping cancer screening at the age of 75. In private health systems, extension of screening up to 80-85 years is, based on the life expectancy and the history of screening. Screening remains effective in populations without comorbidity given their better life-expectancy. Serious adverse events of colonoscopy increase with age and can outweigh the benefit of screening. The great majority of reviews concluded that screening between 75 and 85 years must be decided case by case.

CONCLUSION

The current literature does not allow Evidence-Based Medicine propositions for mass screening above 75 years old. As some subjects over 75 years may benefit from CRC screening, we discussed ways to introduce CRC screening in France in the 75-80 age group. IRB: An institutional review board composed of members of the 2 learned societies (SOFOG and FFCD) defined the issues of interest, followed the evolution of the work and reviewed and validated the report.

Diversity of model approaches for breast cancer screening: a review of model assumptions by The Cancer Intervention and Surveillance Network (CISNET) Breast Cancer Groups

The National Cancer Institute-sponsored Cancer Intervention and Surveillance Network program on breast cancer is composed of seven research groups working largely independently to model the impact of screening and adjuvant therapy on breast cancer mortality trends in the US from 1975 to 2000. Each of the groups has chosen a different modeling methodology without purposeful attempt to be in contrast with each other. The seven groups have met biannually since November 2000 to discuss their methodology and results. This article investigates the differences in methodology. To facilitate this comparison, each of the groups submitted a description of their model into a uniformly structured web based ‘model profiler’. Six of the seven models simulate a preclinical natural history that cannot be observed directly with parameters estimated from published evidence concerning screening and therapy effects. The remaining model regards published evidence on intervention effects as prior information and updates that with information from the US population in a Bayesian type analysis. In general, the differences between the models appear to be small, particularly among the models driven by natural history assumptions. However, we demonstrate that such apparently small differences can have a large impact on surveillance of population trends. We describe a systematic approach to evaluating differences in model assumptions and results, as well as differences in modeling culture underlying the differences in model structure and parameters.

Cost-effectiveness of family history-based colorectal cancer screening in Australia

Background

With 14.234 diagnoses and over 4047 deaths reported in 2007, colorectal cancer (CRC) is the second most common cancer and second most common cause of cancer-related mortality in Australia. The direct treatment cost has recently been estimated to be around AU$1.2 billion for the year 2011, which corresponds to a four-fold increase, compared the cost reported in 2001. Excluding CRCs due to known rare genetic disorders, 20% to 25% of all CRCs occur in a familial aggregation setting due to genetic variants or shared environmental risk factors that are yet to be characterised. A targeted screening strategy addressed to this segment of the population is a potentially valuable tool for reducing the overall burden of CRC.

Methods

We developed a Markov model to assess the cost-effectiveness of three screening strategies offered to people at increased risk due to a strong family history of CRC. The model simulated the evolution of a cohort of 10,000 individuals from age 50 to 90 years. We compared screening with biennial iFOBT, five-yearly colonoscopy and ten-yearly colonoscopy versus the current strategy of the Australian National Bowel Cancer Screening Programme (i.e. base case).

Results

Under the NBCSP scenario, 6,491 persons developed CRC with an average screening lifetime cost of AU$3,441 per person. In comparison, screening with biennial iFOBT, colonoscopy every ten years, and colonoscopy every five years reduced CRC incidence by 27%, 35% and 60%, and mortality by 15%, 26% and 46% respectively. All three screening strategies had a cost under AU$50,000 per life year gained, which is regarded as the upper limit of acceptable cost-effectiveness in the Australian health system. At AU$12,405 per life year gained and an average lifetime expectancy of 16.084 years, five-yearly colonoscopy screening was the most cost-effective strategy.

Conclusion

The model demonstrates that intensive CRC screening strategies targeting people at increased risk would be cost-effective in the Australian context. Our findings provide evidence that substantial health benefits can be generated from risk-based CRC screening at a relatively modest incremental cost.

Whole blood viscosity issues VI: Association with blood salicylate level and gastrointestinal bleeding

Background:

This series on whole blood viscosity issues has been trying to elucidate the sensitivity, specificity and usefulness of the laboratory parameter in clinical practice. The postulation has been that since antiplatelet is used in the management of stasis, of which blood viscosity is an index, the latter would be useful laboratory indication and/or contraindication.

Aim:

The aim of this study was to observe whether blood level of acetylsalicylic acid differs with the level of whole blood viscosity.

Patients and Methods:

Out of the ten years database, 538 cases that were concomitantly tested for haematocrit, total proteins and blood level of salicylate were selected for this study. A separate nine cases of positive faecal occult blood tests were audited for blood viscosity and reviewed.

Results:

A statistically significant difference is observed with lower blood viscosity being associated with higher salicylate level in comparison of the former between the highest vs. lowest quartiles (p < 0.002). This observation demonstrates the effect of aspirin in lowering blood stasis. Reviewing the positive faecal occult blood cases indicate that gastrointestinal bleeding is characterized by relative hypoviscosity and that hyperviscosity is not present during bleeding complications.

Conclusion:

The findings affirm that whole blood viscosity is a valid clinical laboratory parameter for evidence-based contraindication, indication and monitoring of antiplatelet medication. It calls for better appreciation and clinical utility of whole blood viscosity, which (in the absence of viscometer) can now be extrapolated from haematocrit and total proteins.

Cost evaluation in a colorectal cancer screening programme by faecal occult blood test in the District of Florence

OBJECTIVES

To evaluate the direct costs of first and repeat colorectal cancer screening by immunochemical faecal occult blood testing (I-FOBT).

METHODS

Florence district residents aged 50-70 were invited to undergo one-time I-FOBT every two years. Full colonoscopy was recommended for FOBT-positive subjects. Direct cost analysis was carried out separately for the first and repeat screening. All relevant resources consumed by the programme were calculated.

RESULTS

Among 25,428 or 62,369 subjects invited to the first or repeat screening, respectively, the corresponding participation rate was 47.8% or 52.3%, and the positivity rate was 4.4% and 3.3%. Corresponding detection rates and positive predictive values for cancer and advanced adenoma were 11.3% or 8.9% and 32.4% or 32.8%, respectively. The assessment phase accounted for the major cost, as compared with recruitment and screening. All cost indicators were slightly higher in the first screening compared with repeat screening. Cost per cancer and advanced adenoma detected was similar in the first or repeat screening. A higher than observed participation rate would have substantially reduced screening cost.

CONCLUSION

Analysis of I-FOBT-organized population-based screening cost demonstrates lower cost at repeat compared with first screening and provides reference for decision-making in screening implementation.

Cancer screening in renal transplant recipients: what is the evidence?

Increased cancer risk is well established in the renal transplant population. Little, however, is known about the benefits and harms of cancer screening, treatment effectiveness, and the overall cancer prognosis in renal transplant recipients. In this study, we critically appraised guidelines for cancer screening in the renal transplant and general populations using standard criteria for an evidence-based screening program. Guidelines were included when they were applied to adult participants, had objectives specific to cancer screening, and were written in English. Recommendations for breast and colorectal cancer screening in the general population were supported by evidence of cancer-specific mortality benefits from randomized, controlled trials of cancer screening. Convincing evidence from observational studies had demonstrated population cervical cancer screening was effective, also, test performance of mammography, faecal occult blood testing, and Pap smear were accurate. Population breast, colorectal, and cervical cancer screening also appeared to be good value for money in the general population. On the contrary, recommendations for cancer screening in renal transplant recipients were entirely extrapolated from data in the general population. Studies in the general population have led to the development of cancer screening guidelines in transplant recipients. Because of increased cancer risk, differences in diagnostic test performance, competing risks for deaths from causes such as cardiovascular disease and reduced overall life expectancies, validity of their recommendations are uncertain. Future studies are needed to address these issues to provide the necessary evidence for informed decision-making.

Cutting cost and increasing access to colorectal cancer screening: another approach to following the guidelines

CONTEXT

Through medical decision making, physicians in the U.S. influence the spending of >$1.3 trillion or 15% of the gross domestic product. U.S. physicians are challenged to identify areas of clinical practice to improve while cutting cost and increasing access. Primary screening for colorectal cancer is a good example to illustrate this point.

OBJECTIVE

To apply a population-based method of medical decision making in the area of primary screening for colorectal cancer in order to illustrate a reduction in health care costs while increasing access and maintaining quality of care.

DESIGN

We used a combination of (a) census population data, (b) National Cancer Institute Survey data on screening rates, and (c) charge data to estimate the current costs of colorectal cancer screening. We also estimated cost and capacity increases that would occur under various other screening scenarios. These included all currently screened subjects receiving annual fecal occult blood testing (FOBT), all currently unscreened individuals undergoing either colonoscopy every decade or annual FOBT, and all eligible subjects undergoing annual FOBT.

MAIN OUTCOME MEASURES

Cost and access differences between current screening activity and other potential scenarios compliant with guidelines.

RESULTS

Screening for colorectal cancer with yearly, six-window, rehydrated FOBT for all normal-risk individuals over the age of 50 has the potential to screen 3,813,095 more Americans for colon cancer yearly than are currently being screened, while costing $8.7 billion less per decade than what is currently being spent on screening a fraction of the population. Looking into the future, it is possible to increase screening rates from 50% to 100%, while saving almost $10 billion per decade by using FOBT for all eligible Americans. In practice, some proportion of these benefits would be realized as the calculations assume a 100% patient compliance rate.

CONCLUSIONS

Considering a population-based approach and the balance among quality, accessibility, and cost parameters, we recommend primary screening for colorectal cancer to be based on yearly six-window, rehydrated FOBT. Colonoscopy due to cost and access issues should be relegated to secondary screening and case finding.

The Economic Impact of False-Positive Cancer Screens

Objective: Despite the promotion and widespread use of routine cancer screening, little is known about the economic consequences of false-positive screening results. We evaluated the medical and nonmedical costs associated with false-positive prostate, lung, colorectal, and ovarian cancer screens.

Method: We identified 1,087 Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial participants enrolled in a large managed care organization. Medical care use and costs were compiled from automated sources and trial data. Nonmedical care costs to patients with a false-positive lung cancer screen were obtained by telephone interview (n = 98).

Results: Forty-three percent of the study sample incurred at least one false-positive cancer screen. The majority of these patients (83%) received follow-up care. Prior to and after controlling for participant characteristics, significantly higher medical care expenditures in the year following screening were found among those with a false-positive screen. The adjusted mean difference was $1,024 for women and $1,171 for men. Among lung cancer screening patients, few nonmedical care costs were identified beyond the time (mean, 1.5 hours) spent receiving care.

Conclusion: The results here indicate that false-positive results among some available cancer screening tests are relatively common, that patients incurring a false-positive screen tend to receive follow-up testing, and that such follow-up is not without associated medical costs. Along with trials evaluating the health benefits of available cancer screening modalities, investigations into potential undesirable consequences of cancer screening are also warranted.

Self-propelling endoscopes

Self-propelling endoscopes offer exciting possibilities for improving access to colon cancer screening, safety of colonoscopy, and efficiency in endoscopy. From an operational perspective, efficiency in endoscopy may be increased or decreased by the introduction of a self-propelling endoscope, depending on the instrument's technical performance characteristics and capabilities, its safety profile, ease of use, the physician time required to review the endoscopic findings, and requirements for sedation, if any. In addition, patient acceptance of such new technology will be a driving force determining its potential for success in the competition for a niche in the diagnostic armamentarium of colon cancer screening.