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Bjørnelv G, Hagen TP, Forma L, Aas E. Care pathways at end-of-life for cancer decedents: registry based analyses of the living situation, healthcare utilization and costs for all cancer decedents in Norway in 2009-2013 during their last 6 months of life. BMC Health Serv Res 2022; 22:1221. [PMID: 36183057 PMCID: PMC9526273 DOI: 10.1186/s12913-022-08526-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/29/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Research on end-of-life care is often fragmented, focusing on one level of healthcare or on a particular patient subgroup. Our aim was to describe the complete care pathways of all cancer decedents in Norway during the last six months of life. METHODS We used six national registries linked at patient level and including all cancer decedents in Norway between 2009-2013 to describe patient use of secondary, primary-, and home- and community-based care. We described patient's car pathway, including patients living situation, healthcare utilization, and costs. We then estimated how cancer type, individual and sociodemographic characteristics, and access to informal care influenced the care pathways. Regression models were used depending on the outcome, i.e., negative binomial (for healthcare utilization) and generalized linear models (for healthcare costs). RESULTS In total, 52,926 patients were included who died of lung (16%), colorectal (12%), prostate (9%), breast (6%), cervical (1%) or other (56%) cancers. On average, patients spent 123 days at home, 24 days in hospital, 16 days in short-term care and 24 days in long-term care during their last 6 months of life. Healthcare utilization increased towards end-of-life. Total costs were high (on average, NOK 379,801). 60% of the total costs were in the secondary care setting, 3% in the primary care setting, and 37% in the home- and community-based care setting. Age (total cost-range NOK 361,363-418,618) and marital status (total cost-range NOK354,100-411,047) were stronger determining factors of care pathway than cancer type (total cost-range NOK341,318- 392,655). When patients died of cancer types requiring higher amounts of secondary care (e.g., cervical cancer), there was a corresponding lower utilization of primary, and home- and community-based care, and vice versa. CONCLUSION Cancer patient's care pathways at end-of-life are more strongly associated with age and access to informal care than underlying type of cancer. More care in one care setting (e.g., the secondary care) is associated with less care in other settings (primary- and home- and community based care setting) as demonstrated by the substitution between the different levels of care in this study. Care at end-of-life should therefore not be evaluated in one healthcare level alone since this might bias results and lead to suboptimal priorities.
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Affiliation(s)
- Gudrun Bjørnelv
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway ,grid.5947.f0000 0001 1516 2393Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Terje P. Hagen
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Leena Forma
- grid.502801.e0000 0001 2314 6254Faculty of Social Sciences, Tampere University, Tampere, Finland ,grid.436211.30000 0004 0400 1203Laurea University of Applied Sciences, Vantaa, Finland
| | - Eline Aas
- grid.5510.10000 0004 1936 8921Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway ,Division for Health Services, Institute of Public Health, Oslo, Norway
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Jin H, Robinson S, Shang W, Achilla E, Aceituno D, Byford S. Overview and Use of Tools for Selecting Modelling Techniques in Health Economic Studies. PHARMACOECONOMICS 2021; 39:757-770. [PMID: 34013440 DOI: 10.1007/s40273-021-01038-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 06/12/2023]
Abstract
The availability and use of tools to guide the choice of modelling technique are not well understood. Our study aims to review existing tools and explore the use of those tools in health economic models. Two reviews and one case study were conducted. Review 1 aimed to identify tools based on expert opinion and citation searching and explore the value of the tools for health economic models. Review 2, based on citation searching, aimed to describe how those tools have been used in health economic models. Both reviews were conducted using Web of Science and Scopus. Two independent reviewers selected studies for inclusion. A case study, focused on economic evaluations of antipsychotic medication in schizophrenia, was conducted to compare the modelling techniques used by existing models with modelling techniques recommended by identified tools. Seven tools were identified, of which the revised Brennan's toolkit, was assessed to be the most appropriate for health economic models. The seven tools were cited 126 times in publications reporting health economic models. Only 17 of these (13.5%) reported that they used the tool(s) to guide the choice of modelling technique. Application of these tools suggested discrete event simulation is most appropriate for modelling antipsychotic medication in schizophrenia, but discrete event simulation was only used by 17% of existing models. There is considerable inconsistency between the modelling techniques used by existing models and modelling techniques recommended by tools. It is recommended that for future modelling studies the choice of modelling technique should be justified, this can be achieved by the application of model selection tools, such as the revised Brennan's toolkit. Future research is required to explore the barriers to using model selection tools in health economic models and to update existing tools and make them easier to use.
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Affiliation(s)
- Huajie Jin
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience at King's College London, The David Goldberg Centre, Box 024, London, SE5 8AF, UK.
| | - Stewart Robinson
- School of Business and Economics, Loughborough University, Epinal Way, Loughborough, LE11 3TU, UK
| | - Wenru Shang
- School of Public Health, Fudan University, No. 130, Dongan Road, Shanghai, 200032, People's Republic of China
| | | | - David Aceituno
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience at King's College London, The David Goldberg Centre, Box 024, London, SE5 8AF, UK
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience at King's College London, The David Goldberg Centre, Box 024, London, SE5 8AF, UK
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Bjørnelv GMW, Edwin B, Fretland ÅA, Deb P, Aas E. Till death do us part: the effect of marital status on health care utilization and costs at end-of-life. A register study on all colorectal cancer decedents in Norway between 2009 and 2013. BMC Health Serv Res 2020; 20:115. [PMID: 32054492 PMCID: PMC7020544 DOI: 10.1186/s12913-019-4794-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/29/2019] [Indexed: 01/11/2023] Open
Abstract
Background Economic analyses of end-of-life care often focus on single aspects of care in selected cohorts leading to limited knowledge on the total level of care required to patients at their end-of-life. We aim at describing the living situation and full range of health care provided to patients at their end-of-life, including how informal care affects formal health care provision, using the case of colorectal cancer. Methods All colorectal cancer decedents between 2009 and 2013 in Norway (n = 7695) were linked to six national registers. The registers included information on decedents’ living situation (days at home, in short- or long-term institution or in the hospital), their total health care utilization and costs in the secondary, primary and home- and community-based care setting. The effect of informal care was assessed through marital status (never married, currently married, or previously married) using regression analyses (negative binominal, two-part models and generalized linear models), controlling for age, gender, comorbidities, education, income, time since diagnosis and year of death. Results The average patient spent four months at home, while he or she spent 27 days in long-term institutions, 16 days in short-term institutions, and 21 days in the hospital. Of the total costs (~NOK 400,000), 58, 3 and 39% were from secondary carers (hospitals), primary carers (general practitioners and emergency rooms) and home- and community-based carers (home care and nursing homes), respectively. Compared to the never married, married patients spent 30 more days at home and utilized less home- and community-based care, but more health care services at the secondary and primary health care level. Their total healthcare costs were significantly lower (−NOK 65,621) than the never married. We found similar, but weaker, patterns for those who had been married previously. Conclusion End-of-life care is primarily provided in the secondary and home-and community-based care level, and informal caregivers have a substantial influence on formal end-of-life care provision. Excluding aspects of care such as home and community-based care or informal care in economic analyses of end-of-life care provides a biased picture of the total resources required, and might lead to inefficient resource allocations.
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Affiliation(s)
- Gudrun Maria Waaler Bjørnelv
- The Intervention Centre, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway. .,Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Partha Deb
- Department of Economics, Hunter College, CUNY and NBER, New York, USA
| | - Eline Aas
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Health Service Research Unit, Akershus University Hospital, Lørenskog, Norway
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Thompson MR, O'Leary DP, Flashman K, Asiimwe A, Ellis BG, Senapati A. Clinical assessment to determine the risk of bowel cancer using Symptoms, Age, Mass and Iron deficiency anaemia (SAMI). Br J Surg 2017. [PMID: 28634990 DOI: 10.1002/bjs.10573] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to identify characteristics with independent predictive value for bowel cancer for use in the clinical assessment of patients attending colorectal outpatient clinics. METHODS This was a 22-year (1986-2007) retrospective cohort analysis of data collected prospectively from patients who attended colorectal surgical outpatient clinics in Portsmouth. The data set was split randomly into two groups of patients to generate and validate a predictive model. Multivariable logistic regression was used to create and validate a system to predict outcome. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow test were used to evaluate the model's predictive capability. The likelihood of bowel cancer was expressed as the odds ratio (OR). RESULTS Data from 29 005 patients were analysed. Discrimination of the model for bowel cancer was high in the development (C-statistic 0·87, 95 per cent c.i. 0·85 to 0·88) and validation (C-statistic 0·86, 0·84 to 0·87) groups. The most important co-variables in the final model were: age (OR 3·17-27·10), rectal (OR 31·48) or abdominal (OR 1·83-8·45) mass, iron deficiency anaemia (IDA) (OR 4·42-8·38), rectal bleeding and change in bowel habit in combination (OR 5·37), change in bowel habit without rectal bleeding, with or without abdominal pain (OR 2·12-2·52), and rectal bleeding with no perianal symptoms and without change in bowel habit (OR 2·91). Some 91·5 per cent of bowel cancers presented with these characteristics, 40·4 per cent with a mass and/or IDA. In patients with at least one of these characteristics the overall risk of having cancer was 10·0 (range 6·5-50·4) per cent, compared with 1·1 (0·3-2·3) per cent in patients without them. CONCLUSION A clinical assessment that systematically identifies or excludes four symptom-age combinations, a mass and IDA (SAMI) stratifies patients as having a low and higher risk of having bowel cancer. This could improve patient selection for referral and investigation.
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Affiliation(s)
- M R Thompson
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - D P O'Leary
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - K Flashman
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - B G Ellis
- Swan Surgery General Practice, Petersfield, UK
| | - A Senapati
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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Abstract
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
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Affiliation(s)
- Willie Hamilton
- University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK
| | - Fiona M Walter
- Department of Public Health &Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Wolfson Building, Queen's Campus, University of Durham, Stockton-on-Tees TS17 6BH, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
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Kriza C, Emmert M, Wahlster P, Niederländer C, Kolominsky-Rabas P. Cost of illness in colorectal cancer: an international review. PHARMACOECONOMICS 2013; 31:577-588. [PMID: 23636661 DOI: 10.1007/s40273-013-0055-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Given the current-and increasing-pressure to limit expenditure on health care provision in many countries, a better understanding of the cost burden of colorectal cancer is needed. Cost-of-illness studies and reviews thereof can be a useful tool for analysing and critically evaluating the cost-related development of colorectal cancer, and they highlight important cost drivers. METHODS A systematic review was conducted from 2002 to 2012 to identify cost-of-illness studies related to colorectal cancer, searching the Medline, PubMed, Science Direct, Cochrane Library and the York CRD databases. RESULTS Among the 10 studies (from France, the US, Ireland and Taiwan) included in the review, 6 studies reported prevalence-based estimates and 4 studies focussed on incidence-based data. In the studies included in the review, long-term costs for colorectal cancer of up to $50,175 per patient (2008 values) were estimated. Most of the studies in the review showed that the initial and terminal phases of colorectal cancer care are the most expensive, with continuing treatment being the least costly phase. One study also highlighted that stage I CRC disease was the least costly and stage III the most costly of all 4 stages, due to the high cost impact of biological agents. CONCLUSIONS This review has highlighted a trend for rising costs associated with CRC, which is linked to the increasing use of targeted biological therapies. COI studies in colorectal cancer can identify specific components and areas of care that are especially costly, thereby focussing attention on more cost-effective approaches, which is especially relevant to the increased use of biological agents in the field of personalised medicine. COI studies are an important tool for further health economic evaluations of personalised medicine.
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Affiliation(s)
- Christine Kriza
- Interdisciplinary Centre for Health Technology Assessment and Public Health, University of Erlangen-Nuremberg, National BMBF-Cluster of Excellence Medical Technologies-Medical Valley EMN, Schwabachanlage 6, 91054 Erlangen, Germany.
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Tappenden P, Chilcott J, Brennan A, Squires H, Stevenson M. Whole disease modeling to inform resource allocation decisions in cancer: a methodological framework. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:1127-1136. [PMID: 23244816 DOI: 10.1016/j.jval.2012.07.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 07/10/2012] [Accepted: 07/13/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES This article presents a methodological framework for developing health economic models of whole systems of disease and treatment pathways to inform decisions concerning resource allocation-an approach referred to as "Whole Disease Modeling." This system-level approach can provide a consistent mathematical infrastructure for the economic evaluation of virtually any intervention across a disease pathway. METHODS The framework has been developed for cancer but is broadly generalizable to other diseases. It has been informed by pilot work, a systematic review of economic analyses, a qualitative examination of model development processes, and other literature from the fields of operational research, statistics, and health economics. RESULTS The framework is built on three principles: 1) the model boundary and breadth should capture all relevant aspects of the disease and its treatment-from preclinical disease through to death, 2) the model should be developed such that the decision node is conceptually transferable across the model, and 3) the costs and consequences of service elements should be structurally related. A generalized process for developing Whole Disease Models is presented. DISCUSSION Although this approach involves a nontrivial investment of time and resource, its value may be realized when 1) multiple options for service change require economic analysis at a single time point, 2) a disease service changes rapidly and the model can be reused, 3) current services within a pathway have not been subjected to economic analysis, 4) upstream events are expected to have important downstream effects, or 5) simple cost-utility decision rules fail to reflect the complexity of the decision-makers' objectives.
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Affiliation(s)
- Paul Tappenden
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK.
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Kornmann M, Hebart H, Danenberg K, Goeb R, Staib L, Kron M, Henne-Bruns D, Danenberg P, Link KH. Response prediction in metastasised colorectal cancer using intratumoural thymidylate synthase: Results of a randomised multicentre trial. Eur J Cancer 2012; 48:1443-51. [DOI: 10.1016/j.ejca.2011.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 10/18/2011] [Accepted: 11/06/2011] [Indexed: 01/27/2023]
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Sullivan R, Peppercorn J, Sikora K, Zalcberg J, Meropol NJ, Amir E, Khayat D, Boyle P, Autier P, Tannock IF, Fojo T, Siderov J, Williamson S, Camporesi S, McVie JG, Purushotham AD, Naredi P, Eggermont A, Brennan MF, Steinberg ML, De Ridder M, McCloskey SA, Verellen D, Roberts T, Storme G, Hicks RJ, Ell PJ, Hirsch BR, Carbone DP, Schulman KA, Catchpole P, Taylor D, Geissler J, Brinker NG, Meltzer D, Kerr D, Aapro M. Delivering affordable cancer care in high-income countries. Lancet Oncol 2011; 12:933-80. [PMID: 21958503 DOI: 10.1016/s1470-2045(11)70141-3] [Citation(s) in RCA: 483] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.
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Affiliation(s)
- Richard Sullivan
- Kings Health Partners, King's College, Integrated Cancer Centre, Guy's Hospital Campus, London, UK.
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:207-27. [DOI: 10.1097/spc.0b013e32833e8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JMA, Parkin DM, Wardle J, Duffy SW, Cuzick J. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375:1624-33. [PMID: 20430429 DOI: 10.1016/s0140-6736(10)60551-x] [Citation(s) in RCA: 1096] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal cancer is the third most common cancer worldwide and has a high mortality rate. We tested the hypothesis that only one flexible sigmoidoscopy screening between 55 and 64 years of age can substantially reduce colorectal cancer incidence and mortality. METHODS This randomised controlled trial was undertaken in 14 UK centres. 170 432 eligible men and women, who had indicated on a previous questionnaire that they would accept an invitation for screening, were randomly allocated to the intervention group (offered flexible sigmoidoscopy screening) or the control group (not contacted). Randomisation by sequential number generation was done centrally in blocks of 12, with stratification by trial centre, general practice, and household type. The primary outcomes were the incidence of colorectal cancer, including prevalent cases detected at screening, and mortality from colorectal cancer. Analyses were intention to treat and per protocol. The trial is registered, number ISRCTN28352761. FINDINGS 113 195 people were assigned to the control group and 57 237 to the intervention group, of whom 112 939 and 57 099, respectively, were included in the final analyses. 40 674 (71%) people underwent flexible sigmoidoscopy. During screening and median follow-up of 11.2 years (IQR 10.7-11.9), 2524 participants were diagnosed with colorectal cancer (1818 in control group vs 706 in intervention group) and 20 543 died (13 768 vs 6775; 727 certified from colorectal cancer [538 vs 189]). In intention-to-treat analyses, colorectal cancer incidence in the intervention group was reduced by 23% (hazard ratio 0.77, 95% CI 0.70-0.84) and mortality by 31% (0.69, 0.59-0.82). In per-protocol analyses, adjusting for self-selection bias in the intervention group, incidence of colorectal cancer in people attending screening was reduced by 33% (0.67, 0.60-0.76) and mortality by 43% (0.57, 0.45-0.72). Incidence of distal colorectal cancer (rectum and sigmoid colon) was reduced by 50% (0.50, 0.42-0.59; secondary outcome). The numbers needed to be screened to prevent one colorectal cancer diagnosis or death, by the end of the study period, were 191 (95% CI 145-277) and 489 (343-852), respectively. INTERPRETATION Flexible sigmoidoscopy is a safe and practical test and, when offered only once between ages 55 and 64 years, confers a substantial and longlasting benefit. FUNDING Medical Research Council, National Health Service R&D, Cancer Research UK, KeyMed.
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Affiliation(s)
- Wendy S Atkin
- Department of Surgery and Cancer, Imperial College London, London, UK.
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