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Zaika V, Prakash MK, Cheng CY, Schlander M, Lang BM, Beerenwinkel N, Sonnenberg A, Krupka N, Misselwitz B, Poleszczuk J. Optimal timing of a colonoscopy screening schedule depends on adenoma detection, adenoma risk, adherence to screening and the screening objective: A microsimulation study. PLoS One 2024; 19:e0304374. [PMID: 38787836 PMCID: PMC11125540 DOI: 10.1371/journal.pone.0304374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Colonoscopy-based screening provides protection against colorectal cancer (CRC), but the optimal starting age and time intervals of screening colonoscopies are unknown. We aimed to determine an optimal screening schedule for the US population and its dependencies on the objective of screening (life years gained or incidence, mortality, or cost reduction) and the setting in which screening is performed. We used our established open-source microsimulation model CMOST to calculate optimized colonoscopy schedules with one, two, three or four screening colonoscopies between 20 and 90 years of age. A single screening colonoscopy was most effective in reducing life years lost from CRC when performed at 55 years of age. Two, three and four screening colonoscopy schedules saved a maximum number of life years when performed between 49-64 years; 44-69 years; and 40-72 years; respectively. However, for maximum incidence and mortality reduction, screening colonoscopies needed to be scheduled 4-8 years later in life. The optimum was also influenced by adenoma detection efficiency with lower values for these parameters favoring a later starting age of screening. Low adherence to screening consistently favored a later start and an earlier end of screening. In a personalized approach, optimal screening would start earlier for high-risk patients and later for low-risk individuals. In conclusion, our microsimulation-based approach supports colonoscopy screening schedule between 45 and 75 years of age but the precise timing depends on the objective of screening, as well as assumptions regarding individual CRC risk, efficiency of adenoma detection during colonoscopy and adherence to screening.
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Affiliation(s)
- Viktor Zaika
- Faculty of Medicine, Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
- Department of Visceral Surgery and Medicine, Inselspital Bern and Bern University, Bern, Switzerland
| | - Meher K. Prakash
- Theoretical Sciences Unit, Jawaharlal Nehru Center for Advanced Scientific Research, Jakkur, Bangalore, India
| | - Chih-Yuan Cheng
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Brian M. Lang
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland
- SIB Swiss Institute of Bioinformatics, Basel, Switzerland
| | - Niko Beerenwinkel
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland
- SIB Swiss Institute of Bioinformatics, Basel, Switzerland
| | - Amnon Sonnenberg
- The Portland VA Medical Center, P3-GI, Portland, Oregon, United States of America
| | - Niklas Krupka
- Department of Visceral Surgery and Medicine, Inselspital Bern and Bern University, Bern, Switzerland
| | - Benjamin Misselwitz
- Department of Visceral Surgery and Medicine, Inselspital Bern and Bern University, Bern, Switzerland
| | - Jan Poleszczuk
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
- Department of Computational Oncology, Maria Skłodowska-Curie Institute-Oncology Center, Warsaw, Poland
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2
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Allen CJ, Bloom N, Rothka M, Rao P, Wagner PL, Bartlett DL, Farah K, Chalikonda S. Comprehensive Cost Implications of Commercially Available Noninvasive Colorectal Cancer Screening Modalities. J Am Coll Surg 2023; 237:465-472. [PMID: 37219020 DOI: 10.1097/xcs.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND There is an increasing usage of noninvasive screening modalities for colorectal cancer (CRC), primarily the fecal immunochemical test (FIT) and multi-target stool DNA test (Cologuard [CG]). The aim of this study was to determine the comprehensive, long-term cost implications of these noninvasive screening modalities. STUDY DESIGN Using a national insurer-based administrative dataset, patients screened for CRC from January 1, 2019 to December 31, 2019 were analyzed. A hierarchical logic system was used to determine the primary screening modality for each patient. The total annual costs in US dollars ($) were extrapolated using number of patients screened, costs per test, screening intervals, and costs incurred from false results. Patients within our tumor registry diagnosed with CRC were matched to their claims data, and cancer stage distribution was compared. RESULTS Of 119,334 members who underwent noninvasive screening, 38.1% underwent screening with FIT and 40.0% with CG. The combined annual cost for these 2 screening modalities was $13.7 million. By transitioning to FIT alone for all noninvasive screening, the total annual cost would decrease to $7.9 million, resulting in a savings of approximately $5.8 million per year. Additionally, by combining data from the network cancer registry and insurer-based claims dataset, we were able to match 533 individuals who underwent screening and were later diagnosed with CRC. The rate of early-stage (stage 0 to II) disease was found to be similar between those screened with FIT and CG (59.5% FIT vs 63.2% CG; p = 0.77). CONCLUSIONS The adoption of FIT as the primary noninvasive CRC screening method has the potential to generate significant cost savings, and therefore, carries significant value implications for a large population health system.
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Affiliation(s)
- Casey J Allen
- From the Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network, Pittsburgh, PA, (Allen, Rao, Wagener, Chalikonda)
| | - Nathan Bloom
- Right Care Administration, Highmark Health, Pittsburgh, PA (Bloom, Rothka)
| | - Michael Rothka
- Right Care Administration, Highmark Health, Pittsburgh, PA (Bloom, Rothka)
| | - Pavan Rao
- From the Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network, Pittsburgh, PA, (Allen, Rao, Wagener, Chalikonda)
| | - Patrick L Wagner
- From the Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network, Pittsburgh, PA, (Allen, Rao, Wagener, Chalikonda)
| | - David L Bartlett
- Allegheny Health Network Cancer Institute, Pittsburgh, PA (Bartlett)
| | - Katie Farah
- Institute of Medicine, Division of Gastrointestinal Diseases, Allegheny Health Network, Pittsburgh, PA (Farah)
| | - Sricharan Chalikonda
- From the Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network, Pittsburgh, PA, (Allen, Rao, Wagener, Chalikonda)
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Pokharel R, Lin YS, McFerran E, O'Mahony JF. A Systematic Review of Cost-Effectiveness Analyses of Colorectal Cancer Screening in Europe: Have Studies Included Optimal Screening Intensities? APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:701-717. [PMID: 37380865 PMCID: PMC10403417 DOI: 10.1007/s40258-023-00819-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE To assess the range of strategies analysed in European cost-effectiveness analyses (CEAs) of colorectal cancer (CRC) screening with respect to the screening intervals, age ranges and test cut-offs used to define positivity, to examine how this might influence what strategies are found to be optimal, and compare them with the current screening policies with a focus on the screening interval. METHODS We searched PubMed, Web of Science and Scopus for peer-reviewed, model-based CEAs of CRC screening. We included studies on average-risk European populations using the guaiac faecal occult blood test (gFOBT) or faecal immunochemical test (FIT). We adapted Drummond's ten-point checklist to appraise study quality. RESULTS We included 39 studies that met the inclusion criteria. Biennial screening was the most frequently used interval which was analysed in 37 studies. Annual screening was assessed in 13 studies, all of which found it optimally cost-effective. Despite this, 25 of 26 European stool-based programmes use biennial screening. Many CEAs did not vary the age range, but the 14 that did generally found broader ranges optimal. Only 11 studies considered alternative FIT cut-offs, 9 of which found lower cut-offs superior. Conflicts between current policy and CEA evidence are less clear regarding age ranges and cut-offs. CONCLUSIONS The existing CEA evidence indicates that the widely adopted biennial frequency of stool-based testing in Europe is suboptimal. It is likely that many more lives could be saved throughout Europe if programmes could be offered with more intensive annual screening.
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Affiliation(s)
- Rajani Pokharel
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Yi-Shu Lin
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Ethna McFerran
- Patrick G Johnston Centre for Cancer Research, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - James F O'Mahony
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
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4
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Kupper BEC, Ferreira FO, Nakagawa WT, Calsavara VF, Chulam TC, Lopes A, Aguiar-Junior S. COLORECTAL CANCER: ASSOCIATION BETWEEN SOCIODEMOGRAPHIC VARIABLES AND THE ADHERENCE TO CANCER SCREENING. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1729. [PMID: 37194861 DOI: 10.1590/0102-672020230002e1729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/30/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is a worldwide health problem whose control depends on public policy establishment and effective prevention and screening programs. In Brazil, there are few studies related to adherence to screening methods. AIMS The aim of this study was to evaluate the association between demographic and socioeconomic to adherence to CRC screening with fecal immunochemical test (FIT) among average-risk individuals for CRC. METHODS In this prospective cross-sectional study, conducted between March 2015 and April 2016, 1,254 asymptomatic individuals aged 50-75 years, participating in a hospital screening campaign in Brazil, were invited to participate in the study. RESULTS The adherence rate to FIT was 55.6% (697/1,254). In the multivariable logistic regression analysis, patients aged 60-75 years (odds ratio (OR)=1.30; 95% confidence interval (CI): 1.02-1.66; p=0.03), religious belief (OR=2.04; 95% CI: 1.34-3.11; p<0.01), previous fecal occult blood test (OR=2.07; 95% CI: 1.55-2.76; p<0.01), and full/part-time working status (OR=0.66; 95% CI: 0.49-0.89; p<0.01) were independently associated with adherence to CRC screening. CONCLUSION The results of the present study highlight the importance of considering the labor aspects when implementing screening programs, suggesting that campaigns conducted in the workplace and repeated over the years may be more effective.
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Affiliation(s)
| | | | | | | | - Thiago Celestino Chulam
- AC Camargo Cancer Center, Department of Prevention and Early Diagnosis - São Paulo (SP), Brazil
| | - Ademar Lopes
- AC Camargo Cancer Center, Colorectal Cancer Department - São Paulo (SP), Brazil
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McFerran E, O’Mahony JF, Naber S, Sharp L, Zauber AG, Lansdorp-Vogelaar I, Kee F. Colorectal Cancer Screening within Colonoscopy Capacity Constraints: Can FIT-Based Programs Save More Lives by Trading off More Sensitive Test Cutoffs against Longer Screening Intervals? MDM Policy Pract 2022; 7:23814683221097064. [PMID: 35573867 PMCID: PMC9091364 DOI: 10.1177/23814683221097064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction. Colorectal cancer (CRC) prevention programs using
fecal immunochemical testing (FIT) in screening rely on colonoscopy for
secondary and surveillance testing. Colonoscopy capacity is an important
constraint. Some European programs lack sufficient capacity to provide optimal
screening intensity regarding age ranges, intervals, and FIT cutoffs. It is
currently unclear how to optimize programs within colonoscopy capacity
constraints. Design. Microsimulation modeling, using the
MISCAN-Colon model, was used to determine if more effective CRC screening
programs can be identified within constrained colonoscopy capacity. A total of
525 strategies were modeled and compared, varying 3 key screening parameters:
screening intervals, age ranges, and FIT cutoffs, including previously
unevaluated 4- and 5-year screening intervals (using a lifetime horizon and 100%
adherence). Results were compared with the policy decisions taken in Ireland to
provide CRC screening within available colonoscopy capacity. Outcomes estimated
net costs, quality-adjusted life-years (QALYs), and required colonoscopies. The
optimal strategies within finite colonoscopy capacity constraints were
identified. Results. Combining a reduced FIT cutoff of 10 µg Hb/g,
an extended screening interval of 4 y and an age range of 60–72 y requires 6%
fewer colonoscopies, reduces net costs by 23% while preventing 15% more CRC
deaths and saving 16% more QALYs relative to a strategy (FIT 40 µg Hb/g,
2-yearly, 60–70 year) approximating current policy. Conclusion.
Previously overlooked longer screening intervals may optimize cancer prevention
with finite colonoscopy capacity constraints. Changes could save lives, reduce
costs, and relieve colonoscopy capacity pressures. These findings are relevant
to CRC screening programs across Europe that employ FIT-based testing, which
face colonoscopy capacity constraints.
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Affiliation(s)
- Ethna McFerran
- Queen’s University Belfast, Centre for Public Health, Institute of Clinical Sciences, Royal Victoria Hospital, Grosvenor Road, Belfast, UK
| | - James F. O’Mahony
- Centre for Health Policy and Management, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | | | | | - Ann G. Zauber
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Frank Kee
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
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6
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Hoffmeister M. Interim evaluation of the colorectal cancer screening programme in the Netherlands. Lancet Gastroenterol Hepatol 2021; 7:8-9. [PMID: 34822761 DOI: 10.1016/s2468-1253(21)00392-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg 69120, Germany.
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7
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Breekveldt ECH, Lansdorp-Vogelaar I, Toes-Zoutendijk E, Spaander MCW, van Vuuren AJ, van Kemenade FJ, Ramakers CRB, Dekker E, Nagtegaal ID, Krul MF, Kok NFM, Kuhlmann KFD, Vink GR, van Leerdam ME, Elferink MAG. Colorectal cancer incidence, mortality, tumour characteristics, and treatment before and after introduction of the faecal immunochemical testing-based screening programme in the Netherlands: a population-based study. Lancet Gastroenterol Hepatol 2021; 7:60-68. [PMID: 34822762 DOI: 10.1016/s2468-1253(21)00368-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND In 2014, a population-based colorectal cancer (CRC) screening programme was stepwise implemented in the Netherlands comprising faecal immunochemical testing once every 2 years, with a cutoff value for positivity of 47 μg haemoglobin per g faeces. We aimed to assess CRC incidence, mortality, tumour characteristics, and treatment before and after introduction of this screening programme. METHODS We did a retrospective, observational, population-based study in the Netherlands and gathered CRC incidence data from the Netherlands Cancer Registry from Jan 1, 2010, to Dec 31, 2019, in people aged 55 years or older. Patients with a CRC diagnosis between Jan 1, 2014, and Dec 31, 2018, in the Netherlands Cancer Registry were linked with the nationwide registry of histopathology and cytopathology (PALGA) to identify mode of detection (ie, screening-detected vs clinically detected). We calculated age-standardised CRC incidence rates and used data from Statistics Netherlands to calculate CRC-related mortality in 2010-19. We compared localisation, stage distribution, and treatment of screening-detected CRCs with clinically detected CRCs diagnosed in 2014-18 in patients aged 55-75 years. FINDINGS Between Jan 1, 2010, and Dec 31, 2019, 125 215 CRCs were diagnosed in individuals aged 55 years or older and were included in the analyses for CRC incidence. Before the introduction of the screening programme, the age-standardised CRC incidence rate was 214·3 per 100 000 population in 2013 in people aged 55 years or older. After the introduction of the screening programme, this rate initially increased to 259·2 per 100 000 population in 2015, and subsequently decreased to 181·5 per 100 000 population in 2019. Age-standardised incidence rates for advanced CRCs (stage III and IV) were 117·0 per 100 000 population in 2013 and increased to 122·8 per 100 000 population in 2015; this rate then decreased to 94·7 per 100 000 population in 2018. Age-standardised CRC mortality decreased from 87·5 deaths per 100 000 population in 2010 to 64·8 per 100 000 population in 2019. Compared with clinically detected CRCs, screening-detected CRCs were more likely to be located in the left side of the colon (48·6% vs 35·2%) and to be detected at an early stage (I or II; 66·7% vs 46·2%). Screening-detected CRCs were more likely to be treated by local excision compared with clinically detected CRCs, and this finding persisted when stage I CRCs were analysed separately. INTERPRETATION After introduction of this national screening programme, a decrease in overall and advanced-stage CRC incidence was observed. In view of this observation, together with the observed shift to detection at earlier stages and more screening-detected CRCs being treated by local excision, we might cautiously conclude that, in the long-term, faecal immunochemical testing-based screening could ultimately lead to a decrease in CRC-related morbidity and mortality. FUNDING None.
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Affiliation(s)
- Emilie C H Breekveldt
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands.
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Folkert J van Kemenade
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Christian R B Ramakers
- Department of Clinical Chemistry, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre-Location AMC, Amsterdam, Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Myrtle F Krul
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Niels F M Kok
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Koert F D Kuhlmann
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Geraldine R Vink
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
| | - Marloes A G Elferink
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
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Analysis of Post-Colonoscopy Colorectal Cancer and Its Subtypes in a Screening Programme. Cancers (Basel) 2021; 13:cancers13205105. [PMID: 34680254 PMCID: PMC8533900 DOI: 10.3390/cancers13205105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/07/2021] [Accepted: 10/09/2021] [Indexed: 11/17/2022] Open
Abstract
Using the algorithm of the World Endoscopy Organisation (WEO), we have studied retrospectively all colorectal cancers, both detected and non-detected by the Basque Country screening programme from 2009 to 2017. In the screening programme 61,335 colonoscopies were performed following a positive Faecal Immunochemical test (FIT) (≥20 µg Hb/g faeces) and the 128 cases of post-colonoscopy colorectal cancer (PCCRC) detected were analysed. Among them, 50 interval type PCCRCs were diagnosed (before the recommended surveillance), 0.8 cases per 1000 colonoscopies performed, and 78 non-interval type PCCRCs (in the surveillance carried out at the recommended time or delayed), 1.3 per 1000 colonoscopies. Among the non-interval type PCCRCs, 61 cases were detected in the surveillance carried out at the recommended time (type A) and 17 when the surveillance was delayed (type B), 1 case per 1000 colonoscopies performed and 0.28 cases per 1000 colonoscopies performed, respectively. Interval type PCCRC is less frequent than non-interval type PCCRC. In interval type PCCRCs, CRCs detected in advanced stages (stages III-IV) were significantly more frequent than those detected in early stages, compared to those of non-interval type PCCRCs (OR = 3.057; 95% CI, 1.410-6.625; p < 0.005). Non-interval type B PCCRCs are less frequent than non-interval type A PCCRCs, but the frequency of advanced stages is higher in interval type B PCCRCs.
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9
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Keys MT, Serra-Burriel M, Martínez-Lizaga N, Pellisé M, Balaguer F, Sánchez A, Bernal-Delgado E, Castells A. Population-based organized screening by faecal immunochemical testing and colorectal cancer mortality: a natural experiment. Int J Epidemiol 2021; 50:143-155. [PMID: 33211822 DOI: 10.1093/ije/dyaa166] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Population-based organized screening programmes for colorectal cancer (CRC) are underway worldwide, with many based on the faecal immunochemical test (FIT). No clinical trials assessing FIT compared with no screening are planned, and few studies have assessed the population impact of such programmes. METHODS Before 2010, 11 out of 50 Spanish provinces initiated population-based organized screening programmes with FIT for an average-risk population aged 50-69 years. We used a quasi-experimental design across Spanish provinces between 1999 and 2016 to evaluate their impact on population age-standardized mortality and incidence rates due to CRC. Difference-in-differences and synthetic control analyses were performed to test for validation of statistical assumptions and to assess the dynamics of screening-associated changes in outcomes over time. RESULTS No differences in outcome trends between exposed (n = 11) and control (n = 36) provinces were observed for up to 7 years preceding the implementation of screening. Relative to controls, exposed provinces experienced a mean increase in age-standardized incidence of 10.08% [95% confidence interval (CI) (5.09, 15.07)] 2 years after implementation, followed by a reduction in age-standardized mortality rates due to CRC of 8.82% [95% CI (3.77, 13.86)] after 7 years. Results were similar for both women and men. No associated changes were observed in adjacent age bands not targeted by screening, nor for 10 other major causes of death in the exposed provinces. CONCLUSIONS FIT-based organized screening in Spain was associated with reductions in population colorectal cancer mortality. Further research is warranted in order to assess the replicability and external validity of our findings, and on gender-specific use of FIT in organized screening.
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Affiliation(s)
- Matthew T Keys
- Department of Public Health, Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense, Denmark.,Department of Economics, Center for Research in Health and Economics (CRES), Pompeu Fabra University, Barcelona, Spain
| | - Miquel Serra-Burriel
- Department of Economics, Center for Research in Health and Economics (CRES), Pompeu Fabra University, Barcelona, Spain
| | - Natalia Martínez-Lizaga
- Data Science in Health Services and Policy Research, Institute for Health Sciences in Aragón (IACS), Zaragoza, Spain.,Spanish Health Services Research Network on Chronic Diseases (REDISSEC), Zaragoza, Spain
| | - Maria Pellisé
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, Barcelona, Spain
| | - Francesc Balaguer
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, Barcelona, Spain
| | - Ariadna Sánchez
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, Barcelona, Spain
| | - Enrique Bernal-Delgado
- Data Science in Health Services and Policy Research, Institute for Health Sciences in Aragón (IACS), Zaragoza, Spain.,Spanish Health Services Research Network on Chronic Diseases (REDISSEC), Zaragoza, Spain
| | - Antoni Castells
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, Barcelona, Spain
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10
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Zorzi M, Battagello J, Fiore AR, Memo L, Senore C, Rugge M. Colorectal cancer incidence and mortality after negative fecal immunochemical tests by age 70: A prospective observational study. Int J Cancer 2021; 149:1257-1265. [PMID: 33990953 DOI: 10.1002/ijc.33682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022]
Abstract
Limited endoscopy capacity usually represents the main barrier to the extension of screening to subjects older than 70, given the high positivity rate in this age group. We assessed CRC incidence and mortality by number of previous negative fecal immunochemical tests (FIT) among subjects turning 70. We selected persons aged 70 years who had received their last screening invitation when they were 68 or 69 years old within the population-based screening program in the Veneto region of Italy. Subjects with a positive FIT were excluded. We calculated 10-year cumulative CRC incidence and mortality in cohorts of subjects having performed zero, one, two or three negative FITs over the last three screening rounds before turning 70. Out of 117 858 subjects included in the study (46.4% men), 33.7% had never participated in screening (zero negative FITs), 23.3% had had one-negative FIT, 20.1% two-negative FITs and 22.9% three negative FITs. The 10-year cumulative CRC incidence was 29.7 per 1000 subjects with zero FITs, and respectively, 14.5, 11.7 and 9.6 per 1000 subjects with one, two and three negative FITs. The corresponding figures for 10-year cumulative mortality were 9.3, 3.5, 2.2 and 2.1 per 1000 in the four study cohorts. Figures were roughly double for men than for women for all the study cohorts. In order to use more efficiently limited endoscopy resources, and to minimize the potential harms related to false positive results in the elderly, screening among people aged 70 to 74 might be restricted to those with zero previous negative FITs.
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Affiliation(s)
- Manuel Zorzi
- Veneto Tumour Registry, Azienda Zero, Padova, Italy
| | | | | | - Laura Memo
- Veneto Tumour Registry, Azienda Zero, Padova, Italy
| | - Carlo Senore
- Epidemiology and Screening Unit - CPO, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Massimo Rugge
- Veneto Tumour Registry, Azienda Zero, Padova, Italy.,Department of Medicine DIMED Pathology and Cytopathology Unit, University of Padova, Padova, Italy
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Pellat A, Deyra J, Husson M, Benamouzig R, Coriat R, Chaussade S. Colorectal cancer screening programme: is the French faecal immunological test (FIT) threshold optimal? Therap Adv Gastroenterol 2021; 14:17562848211009716. [PMID: 33995581 PMCID: PMC8111528 DOI: 10.1177/17562848211009716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 03/23/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In France, the colorectal cancer organised screening programme uses the faecal immunological test. A positive test ⩾30 μg Hb/g of stool leads to a colonoscopy for identification of potential colorectal lesions. Cut-off values vary from 20 to 47 μg Hb/g of stool in Western countries. We herein question this threshold's relevance in a French population and perform a retrospective observational study using the Parisian database between 1 April 2015 and 31 December 2018. METHODS Rates of participation, numbers of positive faecal immunological test (FIT), detection rates and positive predictive values for advanced adenomas and/or colorectal cancer were determined. Mean positivity values for colorectal lesions were calculated. RESULTS In our population, there were 4.1% positive tests and 67.6% colonoscopy results available with final reports. Positive predictive value for advanced adenomas and colorectal cancer were 30% [95% confidence interval (CI) 29.8-30.3] and 7.4% (95% CI 7.35-7.52), respectively. The mean positivity value for all positive tests in our population was 101.7 µg Hb/g of stool (95% CI 85-118.3). There were 1136 normal colonoscopies (21.4%) with a mean positivity value of 88.6 μg Hb/g of stool. Following a negative test in a first screening campaign, 40.8% of patients in our population performed a second test with a positivity rate of 1.3% and with the encounter of 81 colorectal cancers. The risk of having a positive test during the second screening campaign and finding advanced colorectal lesions significantly increased (all p < 0.001) when comparing negative FIT results ranging between 15 and 29 μg Hb/g of stool to 0 and 14 μg Hb/g of stool from the previous campaign. CONCLUSION Using the current positivity threshold, some patients were considered negative with a delay in colorectal cancer diagnosis, suggesting the threshold could be lowered. Also, the mean positivity value for normal colonoscopies was high, raising the question of upper gastrointestinal bleeding.
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Affiliation(s)
| | | | | | - Robert Benamouzig
- Gastroenterology and Digestive Oncology Unit, Avicenne Teaching Hospital, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
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12
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Benamouzig R, Barré S, Saurin JC, Leleu H, Vimont A, Taleb S, De Bels F. Cost-effectiveness analysis of alternative colorectal cancer screening strategies in high-risk individuals. Therap Adv Gastroenterol 2021; 14:17562848211002359. [PMID: 33953799 PMCID: PMC8042553 DOI: 10.1177/17562848211002359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/15/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Current guidelines recommend colonoscopy every 3-5 years for colorectal cancer (CRC) screening of individuals with a familial history of CRC. The objective of this study was to compare the cost effectiveness of screening alternatives in this population. METHODS Eight screening strategies were compared with no screening: fecal immunochemical test (FIT), Stool DNA and blood-based screening every 2 years, colonoscopy, computed tomography colonography, colon capsules, and sigmoidoscopy every 5 years, and colonoscopy at 45 years followed, if negative, by FIT every 2 years. Screening test and procedures performance were obtained from the literature. A microsimulation model reproducing the natural history of CRC was used to estimate the cost (€2018) and effectiveness [quality-adjusted life-years (QALYs)] of each strategy. A lifetime horizon was used. Costs and effectiveness were discounted at 3.5% annually. RESULTS Compared with no screening, colonoscopy and sigmoidoscopy at a 30% uptake were the most effective strategy (46.3 and 43.9 QALY/1000). FIT at a 30 µg/g threshold with 30% uptake was only half as effective (25.7 QALY). Colonoscopy was associated with a cost of €484,000 per 1000 individuals whereas sigmoidoscopy and FIT were associated with much lower costs (€123,610 and €66,860). Incremental cost-effectiveness rate for FIT and sigmoidoscopy were €2600/QALY (versus no screening) and €3100/QALY (versus FIT), respectively, whereas it was €150,000/QALY for colonoscopy (versus sigmoidoscopy). With a lower threshold (10 µg/g) and a higher uptake of 45%, FIT was more effective and less costly than colonoscopy at a 30% uptake and was associated with an incremental cost-effectiveness ratio (ICER) of €4240/QALY versus no screening. CONCLUSION At 30% uptake, current screening is the most effective screening strategy for high-risk individuals but is associated with a high ICER. Sigmoidoscopy and FIT at lower thresholds (10 µg/g) and a higher uptake should be given consideration as cost-effective alternatives. PLAIN LANGUAGE SUMMARY Cost-effectiveness analysis of colorectal cancer screening strategies in high-risk individuals Fecal occult blood testing with an immunochemical test (FIT) is generally considered as the most cost-effective alternative in colorectal cancer screening programs for average risk individuals without family history.Current screening guidelines for high-risk individuals with familial history recommend colonoscopy every 3-5 years.Colonoscopy every 3-5 years for individuals with familial history is the most effective strategy but is associated with a high incremental cost-effectiveness ratio.Compared with colonoscopy, if screening based on FIT is associated with a higher participation rate, it can achieve a similar effectiveness at a lower cost.
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Affiliation(s)
- Robert Benamouzig
- Department of Gastroenterology, Hôpital Avicenne (AP-HP), Bobigny, France
| | | | - Jean-Christophe Saurin
- Department of Endoscopy and Gastroenterology, Pavillon L, Edouard Herriot Hospital (Hospices Civils de Lyon), Lyon, France
| | - Henri Leleu
- Public Health Expertise, 157 rue du faubourg saint-Antoine, Paris, 75011, France
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13
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Liu F, Long Q, He H, Dong S, Zhao L, Zou C, Wu W. Combining the Fecal Immunochemical Test with a Logistic Regression Model for Screening Colorectal Neoplasia. Front Pharmacol 2021; 12:635481. [PMID: 33897424 PMCID: PMC8058550 DOI: 10.3389/fphar.2021.635481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/19/2021] [Indexed: 01/05/2023] Open
Abstract
Background: The fecal immunochemical test (FIT) is a widely used strategy for colorectal cancer (CRC) screening with moderate sensitivity. To further increase the sensitivity of FIT in identifying colorectal neoplasia, in this study, we established a classifier model by combining FIT result and other demographic and clinical features. Methods: A total of 4,477 participants were examined with FIT and those who tested positive (over 100 ng/ml) were followed up by a colonoscopy examination. Demographic and clinical information of participants including four domains (basic information, clinical history, diet habits and life styles) that consist of 15 features were retrieved from questionnaire surveys. A mean decrease accuracy (MDA) score was used to select features that are mostly related to CRC. Five different algorithms including logistic regression (LR), classification and regression tree (CART), support vector machine (SVM), artificial neural network (ANN) and random forest (RF) were used to generate a classifier model, through a 10X cross validation process. Area under curve (AUC) and normalized mean squared error (NMSE) were used in the evaluation of the performance of the model. Results: The top six features that are mostly related to CRC include age, gender, history of intestinal adenoma or polyposis, smoking history, gastrointestinal discomfort symptom and fruit eating habit were selected. LR algorithm was used in the generation of the model. An AUC score of 0.92 and an NMSE score of 0.076 were obtained by the final classifier model in separating normal individuals from participants with colorectal neoplasia. Conclusion: Our results provide a new “Funnel” strategy in colorectal neoplasia screening via adding a classifier model filtering step between FIT and colonoscopy examination. This strategy minimizes the need of colonoscopy examination while increases the sensitivity of FIT-based CRC screening.
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Affiliation(s)
- Feiyuan Liu
- Department of Scientific Research, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, China
| | - Qiaoyun Long
- Department of Clinical Research Center, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, China.,Shenzhen Public Service Platform on Tumor Precision Medicine and Molecular Diagnosis, Shenzhen, China
| | - Hui He
- Department of Health Management, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, China
| | - Shaowei Dong
- Department of Clinical Research Center, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, China.,Shenzhen Public Service Platform on Tumor Precision Medicine and Molecular Diagnosis, Shenzhen, China
| | - Li Zhao
- Department of Health Management, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, China
| | - Chang Zou
- Department of Clinical Research Center, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, China.,Shenzhen Public Service Platform on Tumor Precision Medicine and Molecular Diagnosis, Shenzhen, China
| | - Weiqing Wu
- Department of Health Management, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, China
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14
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Gini A, Buskermolen M, Senore C, Anttila A, Novak Mlakar D, Veerus P, Csanádi M, Jansen EEL, Zielonke N, Heinävaara S, Széles G, Segnan N, de Koning HJ, Lansdorp-Vogelaar I. Development and Validation of Three Regional Microsimulation Models for Predicting Colorectal Cancer Screening Benefits in Europe. MDM Policy Pract 2021; 6:2381468320984974. [PMID: 33598546 PMCID: PMC7863172 DOI: 10.1177/2381468320984974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 11/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background. Validated microsimulation models have been shown to be useful tools in providing support for colorectal cancer (CRC) screening decisions. Aiming to assist European countries in reducing CRC mortality, we developed and validated three regional models for evaluating CRC screening in Europe. Methods. Microsimulation Screening Analysis–Colon (MISCAN-Colon) model versions for Italy, Slovenia, and Finland were quantified using data from different national institutions. These models were validated against the best available evidence for the effectiveness of screening from their region (when available): the Screening for COlon REctum (SCORE) trial and the Florentine fecal immunochemical test (FIT) screening study for Italy; the Norwegian Colorectal Cancer Prevention (NORCCAP) trial and the guaiac fecal occult blood test (gFOBT) Finnish population-based study for Finland. When published evidence was not available (Slovenia), the model was validated using cancer registry data. Results. Our three models reproduced age-specific CRC incidence rates and stage distributions in the prescreening period. Moreover, the Italian and Finnish models replicated CRC mortality reductions (reasonably) well against the best available evidence. CRC mortality reductions were predicted slightly larger than those observed (except for the Florentine FIT study), but consistently within the corresponding 95% confidence intervals. Conclusions. Our findings corroborate the MISCAN-Colon reliability in supporting decision making on CRC screening. Furthermore, our study provides the model structure for an additional tool (EU-TOPIA CRC evaluation tool: http://miscan.eu-topia.org) that aims to help policymakers and researchers monitoring or improving CRC screening in Europe.
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Affiliation(s)
- Andrea Gini
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maaike Buskermolen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Carlo Senore
- SC Epidemiology, Screening, Cancer Registry, Città della Salute e della Scienza University Hospital, CPO, Turin, Italy
| | | | | | - Piret Veerus
- National Institute for Health Development, Tallinn, Estonia
| | | | - Erik E L Jansen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nadine Zielonke
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Nereo Segnan
- SC Epidemiology, Screening, Cancer Registry, Città della Salute e della Scienza University Hospital, CPO, Turin, Italy
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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15
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Csanádi M, Gini A, Koning HD, Széles G, Pitter JG, Oroszi B, Pataki P, Fadgyas-Freyler P, Korponai G, Vokó Z, Lansdorp-Vogelaar I. Modeling costs and benefits of the organized colorectal cancer screening programme and its potential future improvements in Hungary. J Med Screen 2020; 28:268-276. [PMID: 33153369 DOI: 10.1177/0969141320968598] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The national population-based colorectal cancer screening programme in Hungary was initiated in December 2018. We aimed to evaluate the current programme and investigate the costs and benefits of potential future changes to overcome the low coverage of the target population. METHODS We performed an economic evaluation from a healthcare payer perspective using an established micro-simulation model (Microsimulation Screening Analysis-Colon). We simulated costs and benefits of screening with fecal immunochemical test in the Hungarian population aged 50-100, investigating also the impact of potential future scenarios which were assumed to increase invitation coverage: improvement of the IT platform currently used by GPs or distributing the tests through pharmacies instead of GPs. RESULTS The model predicted that the current screening programme could lead to 6.2% colorectal cancer mortality reduction between 2018 and 2050 compared to no screening. Even higher reductions, up to 16.6%, were estimated when tests were distributed through pharmacies and higher coverage was assumed. This change in the programme was estimated to require up to 26 million performed fecal immunochemical tests and 1 million colonoscopies for the simulated period. These future scenarios have acceptable cost-benefit ratios of €8000-€8700 per life-years gained depending on the assumed adherence of invited individuals. CONCLUSIONS With its limitations, the current colorectal cancer screening programme in Hungary will have a modest impact on colorectal cancer mortality. Significant improvements in mortality reduction could be made at acceptable costs, if the tests were to be distributed by pharmacies allowing the entire target population to be invited.
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Affiliation(s)
| | - Andrea Gini
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | | | | | | - Gyula Korponai
- National Health Insurance Fund of Hungary, Budapest, Hungary
| | - Zoltán Vokó
- Syreon Research Institute, Budapest, Hungary.,Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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Barré S, Leleu H, Benamouzig R, Saurin JC, Vimont A, Taleb S, De Bels F. Cost-effectiveness analysis of alternative colon cancer screening strategies in the context of the French national screening program. Therap Adv Gastroenterol 2020; 13:1756284820953364. [PMID: 33014138 PMCID: PMC7509710 DOI: 10.1177/1756284820953364] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A nationwide colorectal cancer (CRC) screening program was set up in France from 2009 for average-risk, asymptomatic people aged 50-74 years based on an immunochemical fecal occult blood test [faecal immunochemical test (FIT)] every 2 years, followed by colonoscopy if positive. The European standard recommends a participation rate of 45% for the program to be cost-effective, yet the latest published rate in France was 34%. The objective of this study was to compare the cost effectiveness of screening alternatives taking real-world participation rates into account. METHODS Eight screening strategies were compared, based either on a screening test (Guaiac or FIT testing, blood-based, stool DNA, computed tomography colonography, colon capsules, and sigmoidoscopy) followed by full colonoscopy if positive or direct colonoscopy. A microsimulation model was used to estimate the cost effectiveness associated with each strategy. RESULTS Compared with no screening, FIT was associated with a 14.0 quality-adjusted life year (QALY) increase of €50,520 per 1000 individuals, giving an incremental cost-effectiveness ratio (ICER) of €3600/QALY. Only stool DNA and blood-based testing were associated with a QALY increase compared with FIT, with stool DNA weakly dominated by blood-based testing, and the latter associated with an ICER of €154,600/QALY compared with FIT. All other strategies were dominated by FIT. CONCLUSION FIT every 2 years appears to be the most cost-effective CRC screening strategy when taking into account a real-world participation rate of 34%.
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Affiliation(s)
| | - Henri Leleu
- Public Health Expertise, 157 Rue du Faubourg Saint-Antoine, Paris, 75011, France
| | - R. Benamouzig
- Department of Gastroenterology, Hôpital Avicenne (AP-HP), Bobigny, France
| | - Jean-Christophe Saurin
- Department of Endoscopy and Gastroenterology, Pavillon L, Edouard Herriot Hospital (Hospices Civils de Lyon), Lyon, France
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17
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Sankatsing VDV, Ravesteyn NT, Heijnsdijk EAM, Broeders MJM, Koning HJ. Risk stratification in breast cancer screening: Cost‐effectiveness and harm‐benefit ratios for low‐risk and high‐risk women. Int J Cancer 2020; 147:3059-3067. [DOI: 10.1002/ijc.33126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 03/31/2020] [Accepted: 04/27/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Valérie D. V. Sankatsing
- Department of Public Health Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
| | - Nicolien T. Ravesteyn
- Department of Public Health Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
| | - Eveline A. M. Heijnsdijk
- Department of Public Health Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
| | - Mireille J. M. Broeders
- Department for Health Evidence Radboud University Medical Center Nijmegen The Netherlands
- Dutch Expert Centre for Screening Nijmegen The Netherlands
| | - Harry J. Koning
- Department of Public Health Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
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18
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Tepus M, Yau TO. Non-Invasive Colorectal Cancer Screening: An Overview. Gastrointest Tumors 2020; 7:62-73. [PMID: 32903904 DOI: 10.1159/000507701] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background Colorectal cancer (CRC) follows a protracted stepwise progression, from benign adenomas to malignant adenocarcinomas. If detected early, 90% of deaths are preventable. However, CRC is asymptomatic in its early-stage and arises sporadically within the population. Therefore, CRC screening is a public health priority. Summary Faecal immunochemical test (FIT) is gradually replacing guaiac faecal occult blood test and is now the most commonly used screening tool for CRC screening program globally. However, FIT is still limited by the haemoglobin degradation and the intermittent bleeding patterns, so that one in four CRC cases are still diagnosed in a late stage, leading to poor prognosis. A multi-target stool DNA test (Cologuard, a combination of NDRG4 and BMP3 DNA methylation, KRAS mutations, and haemoglobin) and a plasma SEPT9 DNA methylation test (Epi proColon) are non-invasive tools also approved by the US FDA, but those screening approaches are not cost-effective, and the detection accuracies remain unsatisfactory. In addition to the approved tests, faecal-/blood-based microRNA and CRC-related gut microbiome screening markers are under development, with work ongoing to find the best combination of molecular biomarkers which maximise the screening sensitivity and specificity. Key Message Maximising the detection accuracy with a cost-effective approach for non-invasive CRC screening is urgently needed to further reduce the incidence of CRC and associated mortality rates.
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Affiliation(s)
- Melanie Tepus
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Tung On Yau
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
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19
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Barré S, Leleu H, Vimont A, Kaufmanis A, Gendre I, Taleb S, De Bels F. [Estimated impact of the current colorectal screening program in France]. Rev Epidemiol Sante Publique 2020; 68:171-177. [PMID: 32417153 DOI: 10.1016/j.respe.2020.04.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/13/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Colorectal cancer is the third most common cancer and the second most deadly in France. A Cochrane meta-analysis has confirmed the benefits of colorectal cancer screening. A nationwide colorectal screening program was set up in France in 2009 for medium-risk, asymptomatic people aged 50 to 74 years. It has been based, since 2015, on the Fecal Immunochemical Test. The participation rate for 2016-2017 was 34%, which is lower than the European objectives. The objective of this study was to evaluate the impact of the program at the current participation rate and at rates of 45% and 65%. METHODS The epidemiological impact of the program was estimated from the results of an individual simulation model adapted from the Microsimulation Screening Analysis Colon model, calibrated and transposed to the French context. An initial analysis was conducted to estimate the individual impact of screening and a second for the entire eligible population, at various participation rates. RESULTS The test is associated with a lifetime reduction in the risk of colorectal cancer of 24% for men and 21% for women, and a reduction in the risk of death from colorectal cancer of 51% and 43% respectively. At the current level of participation, the program reduces incidence by 5% and mortality by 14% compared to no organized screening. The impact would be reduced by an additional 3% and 8% for participation rates of 45% and 65% respectively. Similarly, mortality would decrease by an additional 8% and 22%. CONCLUSION These results confirm that in a population at medium risk for colorectal cancer, the organised programme is an effective strategy for reducing its incidence. They also confirm that the achievement of European objectives remains a key issue for improving the effectiveness of organized screening. An evolution of immunological test delivery modalities could help to achieve these participation objectives.
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Affiliation(s)
- S Barré
- Institut national du cancer, Boulogne-Billancourt, France
| | - H Leleu
- Public Health Expertise, Paris, France
| | - A Vimont
- Public Health Expertise, Paris, France
| | - A Kaufmanis
- Centre de coordination des dépistages des cancers - région Île-de-France, Paris, France
| | - I Gendre
- Centre de coordination des dépistages des cancers - région Grand-Est, Vandœuvre-lès-Nancy, France
| | - S Taleb
- Institut national du cancer, Boulogne-Billancourt, France.
| | - F De Bels
- Institut national du cancer, Boulogne-Billancourt, France
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20
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Lee YC, Hsu CY, Chen SLS, Yen AMF, Chiu SYH, Fann JCY, Chuang SL, Hsu WF, Chiang TH, Chiu HM, Wu MS, Chen HH. Effects of screening and universal healthcare on long-term colorectal cancer mortality. Int J Epidemiol 2020; 48:538-548. [PMID: 30184208 PMCID: PMC6469303 DOI: 10.1093/ije/dyy182] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To evaluate the time trends of colorectal cancer (CRC) affected by a Nationwide Colorectal Cancer Screening (NCCS) programme with biennial faecal immunochemical testing (FIT) and Nationwide Healthcare Insurance (NHI). METHODS Data from the national registries on cancer and death in Taiwan were separated into years 1984-1993, 1994-2003 and 2004-2013 based on the implementations of NHI (starting 1995) and NCCS (starting 2004). The adult population was divided into three age groups (young, 30-49; middle-aged, 50-69; and old, 70-84 years); only the middle-aged were eligible for NCCS. Crude and adjusted effects of NCCS and NHI were quantified by percentage change and 95% confidence interval (CI) with respect to CRC mortality, according to the attributions from incidence and survival. RESULTS Within 335 million person-years of follow-up, 204 362 incident CRCs and 80 771 CRC-related deaths were identified. Increasing mortality trends were noted for 1994-2003 (post-NHI) vs 1984-1993 due to remarkable increasing incidence trends that could not be offset by improved survival as a result of NHI. During 2004-13 (post-NCCS), mortality continued to increase by 15% (95% CI: 10-21%) in young adults (30-49 years) and 8% (95% CI: 6-11%) in older adults (70-84 years), whereas middle-aged adults (50-69 years) had a reduction of 7% (95% CI: 5-9%) due to a remarkable stage shift and subsequent improvement in survival. In the middle-aged adults, increased incidence was less but survival improvement was more compared with other age groups. CONCLUSIONS Whereas universal healthcare insurance led to improvement in CRC survival, FIT-based screening has made an even greater contribution to reducing CRC mortality.
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Affiliation(s)
- Yi-Chia Lee
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Innovation and Policy Center for Population Health and Sustainable Environment, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Sam Li-Sheng Chen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sherry Yueh-Hsia Chiu
- Department of Health Care Management and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan.,Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | | | - Shu-Lin Chuang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Wen-Feng Hsu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Tsung-Hsien Chiang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Innovation and Policy Center for Population Health and Sustainable Environment, College of Public Health, National Taiwan University, Taipei, Taiwan
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21
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Vekic B, Dragojevic-Simic V, Jakovljevic M, Kalezic M, Zagorac Z, Dragovic S, Zivic R, Pilipovic F, Simic R, Jovanovic D, Milovanovic J, Rancic N. A Correlation Study of the Colorectal Cancer Statistics and Economic Indicators in Selected Balkan Countries. Front Public Health 2020; 8:29. [PMID: 32133335 PMCID: PMC7040482 DOI: 10.3389/fpubh.2020.00029] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/31/2020] [Indexed: 12/18/2022] Open
Abstract
Colorectal cancer (CRC) is one of the most commonly diagnosed malignant neoplasms. The aim of the study was to evaluate and correlate most important epidemiological and economic indicators of CRC in 11 selected Balkan countries. The number of new CRC cases was 56,960, and the highest 5-year CRC prevalence was in Slovenia, Croatia, and Greece. Age-standardized CRC incidence rates were highest in Slovenia, Serbia, and Croatia, and age-standardized mortality rates were highest in Croatia, Serbia, and Bulgaria. Current Health Expenditure as % of Gross Domestic Product was the highest in Bosnia and Herzegovina and Serbia. The GDP per capita levels have shown positive correlation with the CRC incidence rate and prevalence. Absolute numbers of new and death-related CRC cases and 5-year prevalence in absolute numbers have shown strong positive correlation with GDP in million current US$. It has been shown that various economic indicators can be linked to the rate of incidence and prevalence of the CRC patients in the selected Balkan countries. Therefore, economic factors can influence the epidemiology of CRC, and heavy CRC burden in the Balkan region may be one of the indexes of the economic development.
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Affiliation(s)
- Berislav Vekic
- Department of Surgery, Clinical Centre Dr. Dragisa Misovic, Belgrade, Serbia.,Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Viktorija Dragojevic-Simic
- Centre for Clinical Pharmacology, Military Medical Academy, Belgrade, Serbia.,Medical Faculty of Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Mihajlo Jakovljevic
- Department of Global Health Economics and Policy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia.,Institute of Comparative Economics, Hosei University, Tokyo, Japan.,N.A. Semashko Department of Public Health and Healthcare, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Marko Kalezic
- Department of Surgery, Clinical Centre Dr. Dragisa Misovic, Belgrade, Serbia
| | - Zagor Zagorac
- Department of Surgery, Clinical Centre Dr. Dragisa Misovic, Belgrade, Serbia
| | - Sasa Dragovic
- Clinic for General Surgery, Military Medical Academy, Belgrade, Serbia
| | - Rastko Zivic
- Department of Surgery, Clinical Centre Dr. Dragisa Misovic, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Filip Pilipovic
- Institute for Orthopedic and Surgical Diseases "Banjica", Belgrade, Serbia
| | - Radoje Simic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department for Plastic Surgery, Institute for Mother and Child Health Care of Serbia Dr. Vukan Cupic, Belgrade, Serbia
| | - Dejan Jovanovic
- Institute of Radiology, Military Medical Academy, Belgrade, Serbia
| | | | - Nemanja Rancic
- Centre for Clinical Pharmacology, Military Medical Academy, Belgrade, Serbia.,Medical Faculty of Military Medical Academy, University of Defence, Belgrade, Serbia.,Institute of Radiology, Military Medical Academy, Belgrade, Serbia
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Diagnostic Accuracy of Stool Tests for Colorectal Cancer Surveillance in Hodgkin Lymphoma Survivors. J Clin Med 2020; 9:jcm9010190. [PMID: 31936745 PMCID: PMC7019558 DOI: 10.3390/jcm9010190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hodgkin lymphoma (HL) survivors have an increased colorectal cancer (CRC) risk. Diagnostic accuracy of quantitative fecal immunochemical testing (FIT, OC Sensor) and/or a multi-target stool DNA test (mt-sDNA, Cologuard®) for advanced neoplasia (AN) was evaluated. METHODS 101 HL survivors underwent a surveillance colonoscopy and were asked to perform two stool tests (FIT and mt-sDNA). Advanced adenoma (AA), advanced serrated lesion (ASL), and AN (AA, ASL, CRC) were evaluated. Sensitivity, specificity, and area under the curve (AUC) for AN were calculated for different FIT cut-offs and mt-sDNA with colonoscopy as reference. RESULTS FIT and mt-sDNA were analyzed in 73 (72%) and 82 (81%) participants, respectively. AN was detected in 19 (26%) and 22 (27%), respectively. AN sensitivities for FIT cut-off of 10 ug Hb/g feces (FIT10) and mt-sDNA were 37% (95% confidence interval (CI): 16-62) and 68% (95% CI: 45-86), with corresponding specificities of 91% (95% CI: 80-97) and 70% (95% CI: 57-86), respectively. AUC for FIT was 0.68 (95% CI: 0.54-0.82) and for mt-sDNA 0.76 (95% CI: 0.63-0.89). CONCLUSIONS In HL survivors, mt-sDNA showed highest sensitivity but with relatively low specificity for AN. Cost-effectiveness analyses is necessary to determine the optimal surveillance strategy.
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van de Veerdonk W, Hoeck S, Peeters M, Van Hal G. Towards risk-stratified colorectal cancer screening. Adding risk factors to the fecal immunochemical test: Evidence, evolution and expectations. Prev Med 2019; 126:105746. [PMID: 31173802 DOI: 10.1016/j.ypmed.2019.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/28/2019] [Accepted: 06/03/2019] [Indexed: 12/24/2022]
Abstract
With increasing incidence and mortality, colorectal cancer (CRC) is a growing health problem worldwide. An effective way to address CRC is by screening for fecal (occult) blood by the fecal immunochemical test (FIT). However, there is room for improvement since precursor lesions and CRC bleed intermittent and can therefore be missed by the FIT (false negatives) or, the detected blood did not result from precursor lesions or CRC (false positives). This review provides the latest evidence on risk prediction models using FIT combined with additional risk factors before colonoscopy, which risk factors to include and if these models will better discriminate between normal findings and CRC compared to the FIT-only. Many prediction models are known for CRC, but compared to the FIT, these are less effective in detecting CRC. The literature search resulted in 645 titles where 11 papers matched the inclusion criteria and were analyzed. Comparing the FIT-only with the risk prediction models for detecting CRC resulted in a significantly increased discrimination for the models. In addition, 2 different risk-stratification categories before colonoscopy were distinguished, namely the 1-model approach which combined risk factors with FIT results in a prediction model while the 2 step approach used risk factors apart from the FIT. Finally, combining FIT with CRC risk factors by means of a model before colonoscopy seems effective regarding discriminative power, however, more research is needed for validation combined with transparent and standardized reporting to improve quality assessment, for which suggestions are reported in this study.
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Affiliation(s)
- Wessel van de Veerdonk
- Faculty of Medicine and Health Sciences, Department of Social Epidemiology and Health Policy (SEHPO), University of Antwerp, Belgium.
| | - Sarah Hoeck
- Faculty of Medicine and Health Sciences, Department of Social Epidemiology and Health Policy (SEHPO), University of Antwerp, Belgium; Centre for Cancer Detection, Bruges, Antwerp, Belgium
| | - Marc Peeters
- Department of Oncology, Antwerp University Hospital, Antwerp, Belgium; Molecular Imaging, Pathology, Radiotherapy & Oncology (MIPRO), University of Antwerp, Belgium
| | - Guido Van Hal
- Faculty of Medicine and Health Sciences, Department of Social Epidemiology and Health Policy (SEHPO), University of Antwerp, Belgium; Centre for Cancer Detection, Bruges, Antwerp, Belgium
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24
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Ran T, Cheng CY, Misselwitz B, Brenner H, Ubels J, Schlander M. Cost-Effectiveness of Colorectal Cancer Screening Strategies-A Systematic Review. Clin Gastroenterol Hepatol 2019; 17:1969-1981.e15. [PMID: 30659991 DOI: 10.1016/j.cgh.2019.01.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Widespread screening for colorectal cancer (CRC) has reduced its incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide up-to-date evidence of the cost effectiveness of CRC screening strategies by answering 3 research questions. METHODS We searched PubMed, National Institute for Health Research Economic Evaluation Database, Social Sciences Citation Index (via the Web of Science), EconLit (American Economic Association) and 3 supplemental databases for original articles published in English from January 2010 through December 2017. All monetary values were converted to US dollars (year 2016). For all research questions, we extracted, or calculated (if necessary), per-person costs and life years (LYs) and/or quality-adjusted LYs, as well as the incremental costs per LY gained or quality-adjusted LY gained compared with the baseline strategy. A cost-saving strategy was defined as one that was less costly and equally or more effective than the baseline strategy. The net monetary benefit approach was used to answer research question 2. RESULTS Our review comprised 33 studies (17 from Europe, 11 from North America, 4 from Asia, and 1 from Australia). Annual and biennial guaiac-based fecal occult blood tests, annual and biennial fecal immunochemical tests, colonoscopy every 10 years, and flexible sigmoidoscopy every 5 years were cost effective (even cost saving in most US models) compared to no screening. In addition, colonoscopy every 10 years was less costly and/or more effective than other common strategies in the United States. Newer strategies such as computed tomographic colonography, every 5 or 10 years, was cost effective compared with no screening. CONCLUSIONS In an updated review, we found that common CRC screening strategies and computed tomographic colonography continued to be cost effective compared to no screening. There were discrepancies among studies from different regions, which could be associated with the model types or model assumptions.
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Affiliation(s)
- Tao Ran
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany.
| | - Chih-Yuan Cheng
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany; Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Benjamin Misselwitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Jasper Ubels
- Division of Health Economics, German Cancer Research Center, Heidelberg, Germany; Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Gibson DJ, Mooney T, Mooney J, Mulcahy HE, O'Donoghue D. Impact of a higher fecal immunochemistry test cut-off on pathology detected in subsequent rounds of a colorectal screening program. Gastrointest Endosc 2019; 89:518-522. [PMID: 30142350 DOI: 10.1016/j.gie.2018.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/01/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Fecal immunochemical test (FIT)-based colorectal cancer (CRC) screening is superior to the traditional binary fecal occult blood test. Its quantitative nature allows the investigator to choose a positivity threshold to match cost and endoscope capacity. The optimal threshold is still debated. BowelScreen, the Irish national colorectal cancer screening program, has a cut-off of 45 μg Hb/g feces, and in this study we investigated the impact of this threshold on pathology detected in round 2 in individuals who had a negative result for round 1 FIT (FIT1). METHODS All individuals with a negative FIT1 result who completed a round 2 FIT (FIT2) 2 years later were included. Pathology outcomes for individuals who had positive FIT2 results were correlated with FIT1 levels. RESULTS A total of 37,877 individuals had negative FIT1 results and completed FIT2. One thousand two hundred thirty (3.2%) had positive FIT2 results (702 men [57%], median age 69, age range 60-70 years). Quantitative analysis showed that at an FIT1 level <5 μg Hb/g feces, 2.3% had positive FIT2 results. At a higher cut-off of 40.1 to 45 μg Hb/g feces, 15.6% of individuals had positive FIT2 results. One thousand two (81.5%) underwent colonoscopy, with clinical outcomes in all cases. Three hundred fifty-one (35%) had normal colonoscopy results. The proportion of individuals with normal colonoscopy results decreased as FIT1 levels rose. Conversely, advanced pathology (CRC + high-risk adenomas) rates rose from 7% to 50% when FIT1 was <5 compared with 40.1 to 45 μg Hb/g feces, respectively. There were 51 screen-detected cancers in round 2 among individuals with negative FIT1 results (22 stage I, 12 stage II, 14 stage III, 3 stage IV). All 3 stage IV individuals had FIT1 results <20 μg Hb/g feces. CONCLUSIONS Varying rates of pathology are observed in round 2 of a screening program based on the quantitative level of a negative round 1 FIT result when the positivity threshold is relatively high. A CRC rate of 5.1% within this group appears acceptable. Although patients with incurable cancer were observed, the positivity threshold to capture these cases within round 1 would have been so sensitive that it would create an unsustainable endoscopy referral burden.
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Affiliation(s)
- David J Gibson
- BowelScreen, The National Bowel Screening Programme, Dublin, Ireland
| | - Therese Mooney
- BowelScreen, The National Bowel Screening Programme, Dublin, Ireland
| | - Jennifer Mooney
- BowelScreen, The National Bowel Screening Programme, Dublin, Ireland
| | - Hugh E Mulcahy
- Centre for Colorectal Disease, St. Vincent's University Hospital, Dublin, Ireland
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26
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Lansdorp-Vogelaar I, Jagsi R, Jayasekera J, Stout NK, Mitchell SA, Feuer EJ. Evidence-based sizing of non-inferiority trials using decision models. BMC Med Res Methodol 2019; 19:3. [PMID: 30612554 PMCID: PMC6322228 DOI: 10.1186/s12874-018-0643-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/13/2018] [Indexed: 12/26/2022] Open
Abstract
Background There are significant challenges to the successful conduct of non-inferiority trials because they require large numbers to demonstrate that an alternative intervention is “not too much worse” than the standard. In this paper, we present a novel strategy for designing non-inferiority trials using an approach for determining the appropriate non-inferiority margin (δ), which explicitly balances the benefits of interventions in the two arms of the study (e.g. lower recurrence rate or better survival) with the burden of interventions (e.g. toxicity, pain), and early and late-term morbidity. Methods We use a decision analytic approach to simulate a trial using a fixed value for the trial outcome of interest (e.g. cancer incidence or recurrence) under the standard intervention (pS) and systematically varying the incidence of the outcome in the alternative intervention (pA). The non-inferiority margin, pA – pS = δ, is reached when the lower event rate of the standard therapy counterbalances the higher event rate but improved morbidity burden of the alternative. We consider the appropriate non-inferiority margin as the tipping point at which the quality-adjusted life-years saved in the two arms are equal. Results Using the European Polyp Surveillance non-inferiority trial as an example, our decision analytic approach suggests an appropriate non-inferiority margin, defined here as the difference between the two study arms in the 10-year risk of being diagnosed with colorectal cancer, of 0.42% rather than the 0.50% used to design the trial. The size of the non-inferiority margin was smaller for higher assumed burden of colonoscopies. Conclusions The example demonstrates that applying our proposed method appears feasible in real-world settings and offers the benefits of more explicit and rigorous quantification of the various considerations relevant for determining a non-inferiority margin and associated trial sample size.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sandra A Mitchell
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Eric J Feuer
- Statistical Research and Applications Branch, Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Room 4E534, Bethesda, MD, 20892-9765, USA.
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27
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Rosso C, Cabianca L, Gili FM. Non-invasive markers to detect colorectal cancer in asymptomatic population. MINERVA BIOTECNOL 2019. [DOI: 10.23736/s1120-4826.18.02493-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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28
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Caron M, Lamarre G, Grégoire P, Simonyan D, Laflamme N. The fecal immunochemical test (fit): Selected aspects regarding its effectiveness for colorectal cancer screening in Quebec City. Prev Med Rep 2018; 12:6-11. [PMID: 30116704 PMCID: PMC6082993 DOI: 10.1016/j.pmedr.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/01/2018] [Accepted: 08/03/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIMS FIT's value has been ascertained across Canada and worldwide, but still needs to be assessed within the province of Quebec. There also remains a gap between formal indications for FIT, and its actual use in clinical practice. This research aims to evaluate some aspects of FIT's effectiveness in our setting, and its application by prescribers. METHODS We retrospectively identified and reviewed all the colonoscopies conducted for a positive FIT in 2014 at 2 hospitals located in Quebec City. RESULTS Five hundred and fifty-nine (559) colonoscopies were reviewed. We obtained PPVs of 6.8% and 46.9% for the detection of CRC and AA, respectively. The PPV for the detection of SCL was higher in men compared to women (OR 1.56, 95%CI 1.11-2.20) and among justified FITs compared to unwarranted ones (OR 1.88, 95%CI 1.34-2.63). The PPV for CRC detection was 25.0% in the presence of unexplained iron deficiency anemia and 6.5% when anemia was absent (p = 0.0058). In 49.9% of cases, the prescription of a FIT was inappropriate. CONCLUSION The FIT holds a better PPV for detecting SCL among men and when it is indicated. Anemia is associated with a higher CRC detection rate. Half of the FITs were not initially indicated.
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Affiliation(s)
- Mireille Caron
- Université Laval Faculty of Medicine, Room 4633, 1050, ave de la Médecine, Québec, QC G1V 0A6, Canada
| | - Gabriel Lamarre
- Université Laval Faculty of Medicine, Room 4633, 1050, ave de la Médecine, Québec, QC G1V 0A6, Canada
| | - Philippe Grégoire
- Centre Hospitalier Universitaire (CHU) de Québec, Hôpital Saint-François d'Assise, 10, Rue de l'Espinay, Québec, QC G1L 3L5, Canada
| | - David Simonyan
- Centre Hospitalier Universitaire de Québec Research Center (CRCHUQ), Hôpital Saint-François-d'Assise, Room D1-719C, 10, rue de l'Espinay, Québec, QC G1L 3L5, Canada
| | - Nathalie Laflamme
- Centre Hospitalier Universitaire de Québec Research Center (CRCHUQ), Hôpital Saint-François-d'Assise, Room D1-719C, 10, rue de l'Espinay, Québec, QC G1L 3L5, Canada
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29
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Rodriguez-Alonso L, Rodriguez-Moranta F, Arajol C, Gilabert P, Serra K, Martin A, Ibáñez-Sanz G, Moreno V, Guardiola J. Proton pump inhibitors reduce the accuracy of faecal immunochemical test for detecting advanced colorectal neoplasia in symptomatic patients. PLoS One 2018; 13:e0203359. [PMID: 30169524 PMCID: PMC6118361 DOI: 10.1371/journal.pone.0203359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 08/20/2018] [Indexed: 02/06/2023] Open
Abstract
Background The faecal immunochemical test (FIT) is used in colorectal cancer (CRC) screening and for the detection of advanced colorectal neoplasia (AN) in symptomatic patients, but its accuracy could be improved. Our objective was to assess the impact of proton pump inhibitors (PPI) on the accuracy of the FIT in the detection of AN, namely advanced colorectal adenoma and CRC. Methods and findings We performed a prospective study of 1002 individuals referred for a diagnostic colonoscopy at Bellvitge University Hospital from September 2011 through to October 2012. An exhaustive interview was performed by a gastroenterologist, prescription drug dispensing database was reviewed and the patient was given a FIT prior to colonoscopy. The positivity threshold of FIT used was ≥ 20 μg Hb/g feces and the main outcome was AN. AN was detected in 13.2% (133) of patients. The accuracy of FIT for detecting AN in the PPI users and non-PPI users were: sensitivity 43.0% vs 65.6%, P = 0.009; specificity 86.9% vs 92.3%, P = 0.010; and, predictive positive value 34.4% vs 55.5%, P = 0.007, respectively. In multivariate analysis, adjusting for potential confounders, PPIs were associated with false positives in AN detection by FIT (OR 1.63 CI 95% 1.02–2.59, P < 0.037). The ROC curve for the FIT in the detection of AN in the PPI users and non-PPI users was 0.68 (CI 95% 0.61–0.76) and 0.85 (CI 95% 0.79–0.90). Conclusions PPI therapy reduces the accuracy of FIT for detecting AN in symptomatic patients.
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Affiliation(s)
- Lorena Rodriguez-Alonso
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
| | | | - Claudia Arajol
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
| | - Pau Gilabert
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
| | - Katja Serra
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
| | - Albert Martin
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
| | - Gemma Ibáñez-Sanz
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
- Catalan Institute of Oncology, Cancer Prevention and Control Programme, IDIBELL, Barcelona, Spain
| | - Victor Moreno
- Catalan Institute of Oncology, Cancer Prevention and Control Programme, IDIBELL, Barcelona, Spain
| | - Jordi Guardiola
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
- * E-mail:
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Arrospide A, Idigoras I, Mar J, de Koning H, van der Meulen M, Soto-Gordoa M, Martinez-Llorente JM, Portillo I, Arana-Arri E, Ibarrondo O, Lansdorp-Vogelaar I. Cost-effectiveness and budget impact analyses of a colorectal cancer screening programme in a high adenoma prevalence scenario using MISCAN-Colon microsimulation model. BMC Cancer 2018; 18:464. [PMID: 29695234 PMCID: PMC5918894 DOI: 10.1186/s12885-018-4362-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 04/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background The Basque Colorectal Cancer Screening Programme began in 2009 and the implementation has been complete since 2013. Faecal immunological testing was used for screening in individuals between 50 and 69 years old. Colorectal Cancer in Basque country is characterized by unusual epidemiological features given that Colorectal Cancer incidence is similar to other European countries while adenoma prevalence is higher. The object of our study was to economically evaluate the programme via cost-effectiveness and budget impact analyses with microsimulation models. Methods We applied the Microsimulation Screening Analysis (MISCAN)-Colon model to predict trends in Colorectal Cancer incidence and mortality and to quantify the short- and long-term effects and costs of the Basque Colorectal Cancer Screening Programme. The model was calibrated to the Basque demographics in 2008 and age-specific Colorectal Cancer incidence data in the Basque Cancer Registry from 2005 to 2008 before the screening begun. The model was also calibrated to the high adenoma prevalence observed for the Basque population in a previously published study. The multi-cohort approach used in the model included all the cohorts in the programme during 30 years of implementation, with lifetime follow-up. Unit costs were obtained from the Basque Health Service and both cost-effectiveness analysis and budget impact analysis were carried out. Results The goodness-of-fit of the model adaptation to observed programme data was evidence of validation. In the cost-effectiveness analysis, the savings from treatment were larger than the added costs due to screening. Thus, the Basque programme was dominant compared to no screening, as life expectancy increased by 29.3 days per person. The savings in the budget analysis appeared 10 years after the complete implementation of the programme. The average annual budget was €73.4 million from year 2023 onwards. Conclusions This economic evaluation showed a screening intervention with a major health gain that also produced net savings when a long follow-up was used to capture the late economic benefit. The number of colonoscopies required was high but remain within the capacity of the Basque Health Service. So far in Europe, no other population Colorectal Cancer screening programme has been evaluated by budget impact analysis. Electronic supplementary material The online version of this article (10.1186/s12885-018-4362-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arantzazu Arrospide
- Gipuzkoa Primary Care - Integrated Health Care Organizations Research Unit, Alto Deba Integrated Health Care Organisation, Avda Navarra 16, 20500, Arrasate-Mondragón, Gipuzkoa, Spain. .,Health Services Research on Chronic Patients Network (REDISSEC), Arrasate - Mondragón, Gipuzkoa, Spain. .,Biodonostia Health Research Institute, Donostia - San Sebastian, Gipuzkoa, Spain.
| | - Isabel Idigoras
- Basque Country Colorectal Cancer Screening Programme, Basque Health Service, Bilbao, Bizkaia, Spain
| | - Javier Mar
- Gipuzkoa Primary Care - Integrated Health Care Organizations Research Unit, Alto Deba Integrated Health Care Organisation, Avda Navarra 16, 20500, Arrasate-Mondragón, Gipuzkoa, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Arrasate - Mondragón, Gipuzkoa, Spain.,Biodonostia Health Research Institute, Donostia - San Sebastian, Gipuzkoa, Spain.,Clinical Management Unit, Alto Deba Integrated Health Care Organisation, Arrasate - Mondragón, Gipuzkoa, Spain
| | - Harry de Koning
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Miriam van der Meulen
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Myriam Soto-Gordoa
- Gipuzkoa Primary Care - Integrated Health Care Organizations Research Unit, Alto Deba Integrated Health Care Organisation, Avda Navarra 16, 20500, Arrasate-Mondragón, Gipuzkoa, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Arrasate - Mondragón, Gipuzkoa, Spain.,Biodonostia Health Research Institute, Donostia - San Sebastian, Gipuzkoa, Spain
| | | | - Isabel Portillo
- Basque Country Colorectal Cancer Screening Programme, Basque Health Service, Bilbao, Bizkaia, Spain
| | | | - Oliver Ibarrondo
- Gipuzkoa Primary Care - Integrated Health Care Organizations Research Unit, Alto Deba Integrated Health Care Organisation, Avda Navarra 16, 20500, Arrasate-Mondragón, Gipuzkoa, Spain
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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31
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Lansdorp-Vogelaar I, Goede SL, Bosch LJ, Melotte V, Carvalho B, van Engeland M, Meijer GA, de Koning HJ, van Ballegooijen M. Cost-effectiveness of High-performance Biomarker Tests vs Fecal Immunochemical Test for Noninvasive Colorectal Cancer Screening. Clin Gastroenterol Hepatol 2018; 16:504-512.e11. [PMID: 28733262 PMCID: PMC5773413 DOI: 10.1016/j.cgh.2017.07.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 06/30/2017] [Accepted: 07/02/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biomarker assays could increase the accuracy of noninvasive detection of colorectal cancer (CRC); fecal immunochemical tests (FITs) are estimated to miss 27%-47% of CRCs and 70%-80% of advanced adenomas per round of screening. We investigated the conditions under which biomarker screens would be cost-effective compared with FIT screens of average-risk individuals. METHODS We used the MISCAN-Colon microsimulation model to estimate the effects of various CRC screening test characteristics on life-years gained (LYG) and; age-specific all-cause mortality was based on the 2010 Dutch life tables. Simulated CRC incidence rate and CRC stage distribution were calibrated to observed data in The Netherlands from 1999 through 2003 (before opportunities for screening). Survival rates after diagnosis of CRC at an age younger than 75 years were based on CRC relative survival data from 1985 through 2004; survival for individuals diagnosed at an age of 75 years or older was adjusted to fit the observed age-increasing mortality/incidence ratio. We modeled FIT along with hypothetical biomarker tests with different test performance levels. For each biomarker test we calculated the maximum unit cost for the test to be cost-effective compared with FIT, assuming a willingness-to-pay threshold of €50,000 ($56,000) per LYG. RESULTS Biennial FIT screening of subjects 55-75 years old provided 84.9 LYG at a cost of €122,000 ($137,000) per 1000 participants. Considering a unit cost of €7 ($8) for FIT (including kit and analysis only, excluding organizational costs), a biomarker test that detects CRC with higher levels of specificity and sensitivity (100%) and advanced adenomas at a proportionally higher level of sensitivity (53%) should never exceed a cost of €51 ($57). The threshold cost could increase to more than €200 ($224) for high-performing biomarker tests in cases of limited colonoscopy capacity or higher uptake of this test. CONCLUSIONS By using the MISCAN-Colon microsimulation model to estimate effects of CRC screening tests, we found that for a biomarker test with increased overall performance to be cost-effective, it should not exceed 7-fold the unit cost of FIT. This maximum would increase substantially if colonoscopy becomes more expensive or scarce, or if the new test has higher screening uptake. These values could be used to estimate the added value of new biomarkers compared with current FIT screening.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - S. Lucas Goede
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Linda J.W. Bosch
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Veerle Melotte
- Department of Pathology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Beatriz Carvalho
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Manon van Engeland
- Department of Pathology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Gerrit A. Meijer
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Harry J. de Koning
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Chen SLS, Hsu CY, Yen AMF, Young GP, Chiu SYH, Fann JCY, Lee YC, Chiu HM, Chiou ST, Chen HH. Demand for Colonoscopy in Colorectal Cancer Screening Using a Quantitative Fecal Immunochemical Test and Age/Sex-Specific Thresholds for Test Positivity. Cancer Epidemiol Biomarkers Prev 2018; 27:704-709. [PMID: 29593012 DOI: 10.1158/1055-9965.epi-17-0387] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 08/09/2017] [Accepted: 03/23/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Despite age and sex differences in fecal hemoglobin (f-Hb) concentrations, most fecal immunochemical test (FIT) screening programs use population-average cut-points for test positivity. The impact of age/sex-specific threshold on FIT accuracy and colonoscopy demand for colorectal cancer screening are unknown.Methods: Using data from 723,113 participants enrolled in a Taiwanese population-based colorectal cancer screening with single FIT between 2004 and 2009, sensitivity and specificity were estimated for various f-Hb thresholds for test positivity. This included estimates based on a "universal" threshold, receiver-operating-characteristic curve-derived threshold, targeted sensitivity, targeted false-positive rate, and a colonoscopy-capacity-adjusted method integrating colonoscopy workload with and without age/sex adjustments.Results: Optimal age/sex-specific thresholds were found to be equal to or lower than the universal 20 μg Hb/g threshold. For older males, a higher threshold (24 μg Hb/g) was identified using a 5% false-positive rate. Importantly, a nonlinear relationship was observed between sensitivity and colonoscopy workload with workload rising disproportionately to sensitivity at 16 μg Hb/g. At this "colonoscopy-capacity-adjusted" threshold, the test positivity (colonoscopy workload) was 4.67% and sensitivity was 79.5%, compared with a lower 4.0% workload and a lower 78.7% sensitivity using 20 μg Hb/g. When constrained on capacity, age/sex-adjusted estimates were generally lower. However, optimizing age/-sex-adjusted thresholds increased colonoscopy demand across models by 17% or greater compared with a universal threshold.Conclusions: Age/sex-specific thresholds improve FIT accuracy with modest increases in colonoscopy demand.Impact: Colonoscopy-capacity-adjusted and age/sex-specific f-Hb thresholds may be useful in optimizing individual screening programs based on detection accuracy, population characteristics, and clinical capacity. Cancer Epidemiol Biomarkers Prev; 27(6); 704-9. ©2018 AACR.
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Affiliation(s)
- Sam Li-Sheng Chen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Graeme P Young
- Flinders Centre for Innovation in Cancer, Flinders University, Australia
| | - Sherry Yueh-Hsia Chiu
- Department of Health Care Management and Healthy Aging Research Center, Chang Gung University, Tao-Yuan, Taiwan.,Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jean Ching-Yuan Fann
- Department of Health Industry Management, School of Healthcare Management, Kainan University, Tao-Yuan, Taiwan
| | - Yi-Chia Lee
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Ti Chiou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Meester RGS, Doubeni CA, Zauber AG, van Ballegooijen M, Corley DA, Lansdorp-Vogelaar I. Impact of adenoma detection on the benefit of faecal testing vs. colonoscopy for colorectal cancer. Int J Cancer 2017; 141:2359-2367. [PMID: 28815573 PMCID: PMC5890914 DOI: 10.1002/ijc.30933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 12/22/2022]
Abstract
Colonoscopy quality, as measured by adenoma detection rates, varies widely across providers and is inversely related to patients' post-colonoscopy cancer risk. This has unknown consequences for the benefits of faecal immunochemical testing (FIT) vs. primary colonoscopy screening for colorectal cancer. Using an established microsimulation model, we predicted the lifetime colorectal cancer incidence and mortality benefits of annual FIT vs. 10-yearly colonoscopy screening at differing ADR levels (quintiles; averages 15.3-38.7%), with colonoscopy performance assumptions estimated from community-based data on physician ADRs and patients' post-colonoscopy risk of cancer. For patients receiving FIT screening with follow-up colonoscopy by physicians from the highest ADR quintile, simulated lifetime cancer incidence and mortality were 28.8 and 5.4 per 1,000, respectively, vs. 20.6 and 4.4 for primary colonoscopy screening (risk ratios, RR = 1.40; 95% probability interval (PI), 1.19-1.71 for incidence, and RR = 1.22; 95%PI, 1.02-1.54 for mortality). With every 5% point ADR decrease, lifetime cancer incidence was predicted to increase on average 9.0% for FIT vs. 12.3% for colonoscopy, and mortality increased 9.9% vs. 13.3%. In ADR quintile 1, simulated mortality was lower for FIT than colonoscopy screening (10.1 vs. 11.8; RR = 0.85; 95%PI, 0.83-0.90), while incidences were more similar. This suggests that relative cancer incidence and mortality reductions for FIT vs. colonoscopy screening may differ by ADR, with fewer predicted deaths with colonoscopy screening in higher ADR settings and fewer deaths with annual FIT screening in lower ADR settings.
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Affiliation(s)
- Reinier G S Meester
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Szilagyi A, Xue X. Evaluation of a fecal immunochemistry test prior to colonoscopy for outpatients with various indications. Clin Exp Gastroenterol 2017; 10:285-292. [PMID: 29184430 PMCID: PMC5689031 DOI: 10.2147/ceg.s147928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Stool tests can predict advanced neoplasms prior to colonoscopy. Results of immunochemical stool tests to predict findings at colonoscopy for various indications are less often reported. We compared pre-colonoscopy stool tests with findings in patients undergoing colonoscopy for different indications. PATIENTS AND METHODS Charts of patients undergoing elective or semi-urgent colonoscopy were reviewed. Comparison of adenoma detection rates and pathological findings was made between prescreened and non-prescreened, and between stool-positive and stool-negative cases. Demographics, quality of colonoscopy, and pathological findings were recorded. Odds ratios (ORs) and 95% confidence intervals (CIs) were assessed. Statistical significance was accepted at p≤0.05. RESULTS Charts of 325 patients were reviewed. Among them, stool tests were done on 144 patients: 114 were negative and 30 were positive. Findings were similar in the pretest and non-pretest groups. Detection of advanced adenomas per patient was higher in the stool-positive group compared to the stool-negative group (23.4% vs 3.5%, p=0.0016, OR =7.6 [95% CI: 2-29.3]). Five advanced adenomas (without high-grade dysplasia or adenocarcinoma) and several cases of multiple adenomas were missed in the negative group. Sensitivity and specificity for advanced polyps was 63.6% and 82.7%, respectively. The negative predictive value was 96.5%. Male gender was independently predictive of any adenoma. CONCLUSION The stool immunochemical test best predicted advanced neoplasms and had a high negative predictive value in this small cohort. Whether this test can be applied to determine the need for colonoscopy in groups other than average risk would require more studies.
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Affiliation(s)
| | - Xiaoqing Xue
- Division of Emergency Medicine, Jewish General Hospital, McGill University School of Medicine, Montreal, Quebec, Canada
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35
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Sarakarn P, Promthet S, Vatanasapt P, Tipsunthonsak N, Jenwitheesuk K, Maneenin N, Jirapornkul C, Kamsa-ard S, Haengsorn T, Arkkhaboot C, Chen SLS, Yen AMF, Chiu SYH, Fann JCY, Chen THH. Preliminary Results: Colorectal Cancer Screening Using Fecal Immunochemical Test (FIT) in a Thai Population Aged 45-74 Years: A Population-Based Randomized Controlled Trial. Asian Pac J Cancer Prev 2017; 18:2883-2889. [PMID: 29072830 PMCID: PMC5747418 DOI: 10.22034/apjcp.2017.18.10.2883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective: The aim of this paper is to provide some details and the results to date of a colorectal cancer screening trial using a fecal immunochemical test (FIT). Methods: A population-based randomized controlled trial began in May, 2016. All people aged 45 to 74 years living in Nam Phong District, Khon Kaen Province, Thailand, and willing to participate are being recruited using an outreach method. Enrolled participants are randomly allocated by a computer-generated randomization program either to a study arm (receive sample kit for FIT) or to a control arm (no provision of kit). Positive FIT cases are subsequently confirmed by a colonoscopy examination, and negative FIT cases are re-tested with FIT every two years. The preliminary results to date were analysed using descriptive statistics. Results: A total of 1,060 enrolled participants provided a complete set of data. Of those randomly assigned to the study arm and tested by FIT, 92 (8.7%) were found to be positive, 39 (11.5%) males and 53 (7.4%) females. The f-Hb concentrations at the 75th, 90th and 95th percentiles for all age groups were higher in males than in females, and the distributions of f-Hb concentration varied with age, especially at the 95th percentile where f-Hb concentrations increased with age. Conclusion: The preliminary results of our screening trial have indicated that the prevalence of positive FIT cases is higher than in a similar recent and, at the time unique, previous study in Thailand. This finding is especially the case for males and those in the older age groups.
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Affiliation(s)
- Pongdech Sarakarn
- Epidemiology and Biostatistics Department, Faculty of Public Health, Khon Kaen University, Thailand.,ASEAN Cancer Epidemiology and Prevention Research Group, Khon Kaen University, Thailand.
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Hadjipetrou A, Anyfantakis D, Galanakis CG, Kastanakis M, Kastanakis S. Colorectal cancer, screening and primary care: A mini literature review. World J Gastroenterol 2017; 23:6049-6058. [PMID: 28970720 PMCID: PMC5597496 DOI: 10.3748/wjg.v23.i33.6049] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/19/2017] [Accepted: 08/01/2017] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is a common health problem, representing the third most commonly diagnosed cancer worldwide and causing a significant burden in terms of morbidity and mortality, with annual deaths estimated at 700000. The western way of life, that is being rapidly adopted in many regions of the world, is a well discussed risk factor for CRC and could be targeted in terms of primary prevention. Furthermore, the relatively slow development of this cancer permits drastic reduction of incidence and mortality through secondary prevention. These facts underlie primary care physicians (PCPs) being assigned a key role in health strategies that enhance prevention and prompt diagnosis. Herein, we review the main topics of CRC in the current literature, in order to better understand its pathogenesis, risk and protective factors, as well as screening techniques. Furthermore, we discuss preventive and screening policies to combat CRC and the crucial role served by PCPs in their successful implementation. Relevant articles were identified through electronic searches of MEDLINE and through manual searches of reference lists.
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Affiliation(s)
- Athanasios Hadjipetrou
- Primary Health Care Centre of Kissamos, Chania, 73400 Crete, Greece
- First Department of Surgery, Saint George General Hospital of Chania, 73300 Crete, Greece
| | - Dimitrios Anyfantakis
- Primary Health Care Centre of Kissamos, Chania, 73400 Crete, Greece
- First Department of Surgery, Saint George General Hospital of Chania, 73300 Crete, Greece
| | | | - Miltiades Kastanakis
- First Department of Surgery, Saint George General Hospital of Chania, 73300 Crete, Greece
| | - Serafim Kastanakis
- Department of Internal Medicine, Saint George General Hospital of Chania, 73300 Crete, Greece
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37
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Projected effect of fecal immunochemical test threshold for colorectal cancer screening on outcomes and costs for Canada using the OncoSim microsimulation model. J Cancer Policy 2017. [DOI: 10.1016/j.jcpo.2017.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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38
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Haug U, Grobbee EJ, Lansdorp-Vogelaar I, Spaander MCW, Kuipers EJ. Immunochemical faecal occult blood testing to screen for colorectal cancer: can the screening interval be extended? Gut 2017; 66:1262-1267. [PMID: 27006184 DOI: 10.1136/gutjnl-2015-310102] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 02/11/2016] [Accepted: 02/23/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Colorectal cancer (CRC) screening programmes based on faecal immunochemical testing for haemoglobin (FIT) typically use a screening interval of 2 years. We aimed to estimate how alternative FIT strategies that use a lower than usual positivity threshold followed by a longer screening interval compare with conventional strategies. METHODS We analysed longitudinal data of 4523 Dutch individuals (50-74 years at baseline) participating in round I of a one-sample FIT screening programme, of which 3427 individuals also participated in round II after 1-3 years. The cohort was followed until 2 years after round II. In both rounds, a cut-off level of ≥50 ng haemoglobin (Hb)/mL buffer (corresponding to 10 µg Hb/g faeces) was used, representing the standard scenario. We determined the cumulative positivity rate (PR) and the numbers of subjects diagnosed with advanced adenomas (N_AdvAd) and early stage CRC (N_earlyCRC) in the cohort over two rounds of screening (standard scenario) and compared it with hypothetical single-round screening with use of a lower cut-off and omission of the second round (alternative scenario). RESULTS In the standard scenario, the cumulative (ie, round I and II combined) PR, N_AdvAd and N_earlyCRC were 13%, 180% and 26%, respectively. In alternative scenarios using a cut-off level of respectively ≥11 and ≥22 ng/HbmL buffer (corresponding to 2 and 4 µg Hb/g faeces), the PRs were 18% and 13%, the N_AdvAd were 180 and 162 and the N_earlyCRC ranged between 22-27 and 22-26. CONCLUSIONS The diagnostic yield of FIT screening using a lowered positivity threshold in combination with an extended screening interval (up to 5 years) may be similar to conventional FIT strategies. This justifies and motivates further research steps in this direction.
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Affiliation(s)
- Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.,Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Esmée J Grobbee
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Prakash MK, Lang B, Heinrich H, Valli PV, Bauerfeind P, Sonnenberg A, Beerenwinkel N, Misselwitz B. CMOST: an open-source framework for the microsimulation of colorectal cancer screening strategies. BMC Med Inform Decis Mak 2017; 17:80. [PMID: 28583127 PMCID: PMC5460500 DOI: 10.1186/s12911-017-0458-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 04/30/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is a leading cause of cancer-related mortality. CRC incidence and mortality can be reduced by several screening strategies, including colonoscopy, but randomized CRC prevention trials face significant obstacles such as the need for large study populations with long follow-up. Therefore, CRC screening strategies will likely be designed and optimized based on computer simulations. Several computational microsimulation tools have been reported for estimating efficiency and cost-effectiveness of CRC prevention. However, none of these tools is publicly available. There is a need for an open source framework to answer practical questions including testing of new screening interventions and adapting findings to local conditions. METHODS We developed and implemented a new microsimulation model, Colon Modeling Open Source Tool (CMOST), for modeling the natural history of CRC, simulating the effects of CRC screening interventions, and calculating the resulting costs. CMOST facilitates automated parameter calibration against epidemiological adenoma prevalence and CRC incidence data. RESULTS Predictions of CMOST were highly similar compared to a large endoscopic CRC prevention study as well as predictions of existing microsimulation models. We applied CMOST to calculate the optimal timing of a screening colonoscopy. CRC incidence and mortality are reduced most efficiently by a colonoscopy between the ages of 56 and 59; while discounted life years gained (LYG) is maximal at 49-50 years. With a dwell time of 13 years, the most cost-effective screening is at 59 years, at $17,211 discounted USD per LYG. While cost-efficiency varied according to dwell time it did not influence the optimal time point of screening interventions within the tested range. CONCLUSIONS Predictions of CMOST are highly similar compared to a randomized CRC prevention trial as well as those of other microsimulation tools. This open source tool will enable health-economics analyses in for various countries, health-care scenarios and CRC prevention strategies. CMOST is freely available under the GNU General Public License at https://gitlab.com/misselwb/CMOST.
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Affiliation(s)
- Meher K Prakash
- Division of Gastroenterology, University Hospital Zurich (USZ), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Brian Lang
- Department of Biosystems Science and Engineering, ETH Zurich, 4058, Basel, Switzerland.,SIB Swiss Institute of Bioinformatics, 4058, Basel, Switzerland
| | - Henriette Heinrich
- Division of Gastroenterology, University Hospital Zurich (USZ), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Piero V Valli
- Division of Gastroenterology, University Hospital Zurich (USZ), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Peter Bauerfeind
- Division of Gastroenterology, University Hospital Zurich (USZ), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Amnon Sonnenberg
- The Portland VA Medical Center, P3-GI, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA
| | - Niko Beerenwinkel
- Department of Biosystems Science and Engineering, ETH Zurich, 4058, Basel, Switzerland.,SIB Swiss Institute of Bioinformatics, 4058, Basel, Switzerland
| | - Benjamin Misselwitz
- Division of Gastroenterology, University Hospital Zurich (USZ), Rämistrasse 100, 8091, Zurich, Switzerland.
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Aronsson M, Carlsson P, Levin LÅ, Hager J, Hultcrantz R. Cost-effectiveness of high-sensitivity faecal immunochemical test and colonoscopy screening for colorectal cancer. Br J Surg 2017; 104:1078-1086. [PMID: 28561259 DOI: 10.1002/bjs.10536] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/25/2016] [Accepted: 02/08/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Colorectal cancer screening can decrease morbidity and mortality. However, there are widespread differences in the implementation of programmes and choice of strategy. The primary objective of this study was to estimate lifelong costs and health outcomes of two of the currently most preferred methods of screening for colorectal cancer: colonoscopy and sensitive faecal immunochemical test (FIT). METHODS A cost-effectiveness analysis of colorectal cancer screening in a Swedish population was performed using a decision analysis model, based on the design of the Screening of Swedish Colons (SCREESCO) study, and data from the published literature and registries. Lifelong cost and effects of colonoscopy once, colonoscopy every 10 years, FIT twice, FIT biennially and no screening were estimated using simulations. RESULTS For 1000 individuals invited to screening, it was estimated that screening once with colonoscopy yielded 49 more quality-adjusted life-years (QALYs) and a cost saving of €64 800 compared with no screening. Similarly, screening twice with FIT gave 26 more QALYs and a cost saving of €17 600. When the colonoscopic screening was repeated every tenth year, 7 additional QALYs were gained at a cost of €189 400 compared with a single colonoscopy. The additional gain with biennial FIT screening was 25 QALYs at a cost of €154 300 compared with two FITs. CONCLUSION All screening strategies were cost-effective compared with no screening. Repeated and single screening strategies with colonoscopy were more cost-effective than FIT when lifelong effects and costs were considered. However, other factors such as patient acceptability of the test and availability of human resources also have to be taken into account.
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Affiliation(s)
- M Aronsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - P Carlsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - L-Å Levin
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - J Hager
- Departments of Surgery and Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden
| | - R Hultcrantz
- Department of Gastroenterology and Hepatology, Karolinska Institute, Karolinska University Hospital, Solna, Sweden
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41
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Robertson DJ, Lee JK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Rex DK. Recommendations on Fecal Immunochemical Testing to Screen for Colorectal Neoplasia: A Consensus Statement by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2017; 152:1217-1237.e3. [PMID: 27769517 DOI: 10.1053/j.gastro.2016.08.053] [Citation(s) in RCA: 245] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The use of the fecal occult blood test (FOBT) for colorectal cancer (CRC) screening is supported by randomized trials demonstrating effectiveness in cancer prevention and widely recommended by guidelines for this purpose. The fecal immunochemical test (FIT), as a direct measure of human hemoglobin in stool has a number of advantages relative to conventional FOBT and is increasingly used relative to that test. This review summarizes current evidence for FIT in colorectal neoplasia detection and the comparative effectiveness of FIT relative to other commonly used CRC screening modalities. Based on evidence, guidance statements on FIT application were developed and quality metrics for program implementation proposed.
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Affiliation(s)
- Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
| | - Jeffrey K Lee
- University of California, San Francisco Medical Center, San Francisco, California
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, University of Washington School of Medicine, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
| | | | | | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Rigter LS, Spaander MCW, Moons LM, Bisseling TM, Aleman BMP, de Boer JP, Lugtenburg PJ, Janus CPM, Petersen EJ, Roesink JM, Raemaekers JMM, van der Maazen RWM, Cats A, Bleiker EMA, Snaebjornsson P, Carvalho B, Lansdorp-Vogelaar I, Jóźwiak K, Te Riele H, Meijer GA, van Leeuwen FE, van Leerdam ME. Colorectal cancer surveillance in Hodgkin lymphoma survivors at increased risk of therapy-related colorectal cancer: study design. BMC Cancer 2017; 17:112. [PMID: 28173773 PMCID: PMC5297162 DOI: 10.1186/s12885-017-3089-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 01/20/2017] [Indexed: 02/08/2023] Open
Abstract
Background Second primary malignancies are a major cause of excess morbidity and mortality in cancer survivors. Hodgkin lymphoma survivors who were treated with infradiaphragmatic radiotherapy and/or high-dose procarbazine have an increased risk to develop colorectal cancer. Colonoscopy surveillance plays an important role in colorectal cancer prevention by removal of the precursor lesions (adenomas) and early detection of cancer, resulting in improved survival rates. Therefore, Hodgkin lymphoma survivors treated with infradiaphragmatic radiotherapy and/or high-dose procarbazine could benefit from colonoscopy, or other surveillance modalities, which are expected to reduce colorectal cancer incidence and mortality. Current knowledge on clinicopathological and molecular characteristics of therapy-related colorectal cancer is limited. The pathogenesis of such colorectal cancers might be different from the pathogenesis in the general population and therefore these patients might require a different clinical approach. We designed a study with the primary aim to assess the diagnostic yield of a first surveillance colonoscopy among Hodgkin lymphoma survivors at increased risk of colorectal cancer and to compare these results with different screening modalities in the general population. Secondary aims include assessment of the test characteristics of stool tests and evaluation of burden, acceptance and satisfaction of CRC surveillance through two questionnaires. Methods/Design This prospective multicenter cohort study will include Hodgkin lymphoma survivors who survived ≥8 years after treatment with infradiaphragmatic radiotherapy and/or procarbazine (planned inclusion of 259 participants). Study procedures will consist of a surveillance colonoscopy with removal of precursor lesions (adenomas) and 6–8 normal colonic tissue biopsies, a fecal immunochemical test and a stool DNA test. All neoplastic lesions encountered will be classified using relevant histomorphological, immunohistochemical and molecular analyses in order to obtain more insight into colorectal carcinogenesis in Hodgkin lymphoma survivors. The Miscan-model will be used for cost-effectiveness analyses. Discussion Evaluation of the diagnostic performance, patient acceptance and burden of colorectal cancer surveillance is necessary for future implementation of an individualized colorectal cancer surveillance program for Hodgkin lymphoma survivors. In addition, more insight into treatment-induced colorectal carcinogenesis will provide the first step towards prevention and personalized treatment. This information may be extrapolated to other groups of cancer survivors. Trial registration Registered at the Dutch Trial Registry (NTR): NTR4961.
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Affiliation(s)
- Lisanne S Rigter
- Department of Gastroenterology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Leon M Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tanya M Bisseling
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan Paul de Boer
- Department of Hematology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Cecile P M Janus
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Eefke J Petersen
- Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith M Roesink
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - John M M Raemaekers
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Annemieke Cats
- Department of Gastroenterology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands
| | - Eveline M A Bleiker
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Beatriz Carvalho
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Katarzyna Jóźwiak
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hein Te Riele
- Division of Biological Stress Response, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Gerrit A Meijer
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands.
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Robertson DJ, Lee JK, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Rex DK. Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the US Multi-Society Task Force on colorectal cancer. Gastrointest Endosc 2017; 85:2-21.e3. [PMID: 27769516 DOI: 10.1016/j.gie.2016.09.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
| | - Jeffrey K Lee
- University of California, San Francisco Medical Center, San Francisco, California
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, University of Washington School of Medicine, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
| | | | | | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Kapidzic A, van Roon AHC, van Leerdam ME, van Vuuren AJ, van Ballegooijen M, Lansdorp-Vogelaar I, Spijker W, Izelaar K, Hol L, Kuipers EJ. Attendance and diagnostic yield of repeated two-sample faecal immunochemical test screening for colorectal cancer. Gut 2017; 66:118-123. [PMID: 26370109 DOI: 10.1136/gutjnl-2014-308957] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 08/24/2015] [Accepted: 08/26/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Limited data exist on attendance and additional yield of 2-sample faecal immunochemical testing (FIT) screening during multiple rounds. We therefore conducted a population-based colorectal cancer screening trial comparing attendance and yield of repeated 1-sample and 2-sample FIT screenings. DESIGN Two randomly selected groups of average-risk subjects aged 50-74 years were invited for two rounds of either 1-sample (n=5007) or 2-sample (n=3197) FIT (OC-sensor Micro) screening. The test was considered positive if at least one sample was positive (cut-off 50 ng/mL; 10 µg haemoglobin/g). RESULTS The cumulative attendance rate was similar for repeated 1-sample and 2-sample FIT screenings (1-sample FIT: 68.1%; 2-sample FIT: 67.1%, p=0.368). The positivity rate in the second round was lower for 1-sample FIT (6.2%, 95% CI 5.4% to 7.2%) than for 2-sample FIT (8.4%, 95% CI 7.1% to 9.8%, p=0.007), whereas the detection rate of advanced neoplasia (AN, 1-sample FIT: 1.9%, 95% CI 1.2% to 2.2%; 2-sample FIT: 1.7%, 95% CI 1.2% to 2.5%, p=0.861) and the positive predictive value (1-sample FIT: 32%, 95% CI 24% to 40%; 2-sample FIT: 21%, 95% CI 15% to 29%, p=0.075) did not differ. After two rounds of screening, the cumulative diagnostic yield of AN for 1-sample FIT was 29.3 per 1000 invitees, compared with 34.0 for 2-sample FIT (p=0.241). CONCLUSIONS Using 2-sample FIT instead of 1-sample FIT does not result in a higher detection rate of AN in the second round of repeated FIT screening. Furthermore, both strategies lead to a similar yield of AN over two rounds. These findings imply that 1-sample FIT screening is preferred over 2-sample FIT screening.
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Affiliation(s)
- Atija Kapidzic
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Aafke H C van Roon
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Wolfert Spijker
- Regional Organization for Population Screening South-West Netherlands, Rotterdam, The Netherlands
| | - Kirsten Izelaar
- Regional Organization for Population Screening South-West Netherlands, Rotterdam, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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45
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Shahidi N, Cheung WY. Colorectal cancer screening: Opportunities to improve uptake, outcomes, and disparities. World J Gastrointest Endosc 2016; 8:733-740. [PMID: 28042387 PMCID: PMC5159671 DOI: 10.4253/wjge.v8.i20.733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/05/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer screening has become a standard of care in industrialized nations for those 50 to 75 years of age, along with selected high-risk populations. While colorectal cancer screening has been shown to reduce both the incidence and mortality of colorectal cancer, it is a complex multi-disciplinary process with a number of important steps that require optimization before tangible improvements in outcomes are possible. For both opportunistic and programmatic colorectal cancer screening, poor participant uptake remains an ongoing concern. Furthermore, current screening modalities (such as the guaiac based fecal occult blood test, fecal immunochemical test and colonoscopy) may be used or performed suboptimally, which can lead to missed neoplastic lesions and unnecessary endoscopic evaluations. The latter poses the risk of adverse events, such as perforation and post-polypectomy bleeding, as well as financial impacts to the healthcare system. Moreover, ongoing disparities in colorectal cancer screening persist among marginalized populations, including specific ethnic minorities (African Americans, Hispanics, Asians, Indigenous groups), immigrants, and those who are economically disenfranchised. Given this context, we aimed to review the current literature on these important areas pertaining to colorectal cancer screening, particularly focusing on the guaiac based fecal occult blood test, the fecal immunochemical test and colonoscopy.
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46
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Wieten E, Schreuders EH, Nieuwenburg SAV, Hansen BE, Lansdorp-Vogelaar I, Kuipers EJ, Bruno MJ, Spaander MCW. Effects of Increasing Screening Age and Fecal Hemoglobin Cutoff Concentrations in a Colorectal Cancer Screening Program. Clin Gastroenterol Hepatol 2016; 14:1771-1777. [PMID: 27567693 DOI: 10.1016/j.cgh.2016.08.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/25/2016] [Accepted: 08/04/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Several countries have implemented programs to screen for colorectal cancer (CRC) by using the fecal immunochemical test (FIT). These programs vary considerably in age of the population screened and the cutoff concentration of fecal hemoglobin (Hb) used to identify candidates for further evaluation; these variations are usually based on a country's colonoscopy resources. We calculated how increasing the Hb cutoff concentration and screening age affects colonoscopy yield, missed lesions, and demand. METHODS We collected data from 10,008 average-risk individuals in The Netherlands, 50-74 years old, who were invited for an FIT in the first round of a population-based CRC screening program from November 2006 through December 2008. Fecal samples were collected, and levels of Hb were measured by using the OC-sensor Micro analyzer; concentrations ≥10 μg Hb/g feces were considered positive. Subjects with a positive FIT were scheduled for colonoscopy within 4 weeks. Logistic regression analysis was performed to evaluate the association between age and detection of advanced neoplasia. RESULTS In total, 5986 individuals (62%) participated in the study; 503 (8.4%) had a positive test result. Attendance, positive test results, detection of advanced neoplasia, and the FIT's positive predictive value all increased significantly with age (P < .001). Detection of advanced neoplasia ranged from 1.3% in the youngest age group to 6.2% in the oldest group; the positive predictive value of the FIT was 26% in the youngest group and 47% in the oldest group. Increasing the starting age of invitees from 50-74 years to 55-74 years reduced the proportion of subjects who underwent colonoscopy evaluation by 14% and resulted in 9% more subjects with advanced neoplasia being missed. Increasing the cutoff concentration from 10 to 15 μg Hb/g feces reduced the proportion of subjects who underwent colonoscopy evaluation by 11% and resulted in 6% of advanced neoplasia being missed. CONCLUSIONS In an analysis of an average-risk screening population in The Netherlands, we found that detection of advanced neoplasia by FIT increases significantly with age and fecal Hb cutoff concentration. Increasing the cutoff concentration or screening age reduces the numbers of patients who undergo colonoscopy evaluation in FIT-based CRC screening programs. Our findings provide insight in these effects per age category and cutoff concentration and the consequences in terms of missed lesions.
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Affiliation(s)
- Els Wieten
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Eline H Schreuders
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Stella A V Nieuwenburg
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
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47
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Greuter MJE, Berkhof J, Canfell K, Lew JB, Dekker E, Coupé VMH. Resilience of a FIT screening programme against screening fatigue: a modelling study. BMC Public Health 2016; 16:1009. [PMID: 27658454 PMCID: PMC5034628 DOI: 10.1186/s12889-016-3667-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/20/2016] [Indexed: 02/06/2023] Open
Abstract
Background Repeated participation is important in faecal immunochemical testing (FIT) screening for colorectal cancer (CRC). However, a large number of screening invitations over time may lead to screening fatigue and consequently, decreased participation rates. We evaluated the impact of screening fatigue on overall screening programme effectiveness. Methods Using the ASCCA model, we simulated the Dutch CRC screening programme consisting of biennial FIT screening in individuals aged 55–75. We studied the resilience of the programme against heterogeneity in screening attendance and decrease in participation rate due to screening fatigue. Outcomes were reductions in CRC incidence and mortality compared to no screening. Results Assuming a homogenous 63 % participation, i.e., each round each individual was equally likely to attend screening, 30 years of screening reduced CRC incidence and mortality by 39 and 53 %, respectively, compared to no screening. When assuming clustered participation, i.e., three subgroups of individuals with a high (95 %), moderate (65 %) and low (5 %) participation rate, screening was less effective; reductions were 33 % for CRC incidence and 43 % for CRC mortality. Screening fatigue considerably reduced screening effectiveness; if individuals refrained from screening after three negative screens, model-predicted incidence reductions decreased to 25 and 18 % under homogenous and clustered participation, respectively. Figures were 34 and 25 % for mortality reduction. Conclusions Screening will substantially decrease CRC incidence and mortality. However, screening effectiveness can be seriously compromised if screening fatigue occurs. This warrants careful monitoring of individual screening behaviour and consideration of targeted invitation systems in individuals who have (repeatedly) missed screening rounds.
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Affiliation(s)
- Marjolein J E Greuter
- Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing, 1007 MB, Amsterdam, The Netherlands.
| | - Johannes Berkhof
- Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing, 1007 MB, Amsterdam, The Netherlands
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia.,School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Jie-Bin Lew
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Veerle M H Coupé
- Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing, 1007 MB, Amsterdam, The Netherlands
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48
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Pil L, Fobelets M, Putman K, Trybou J, Annemans L. Cost-effectiveness and budget impact analysis of a population-based screening program for colorectal cancer. Eur J Intern Med 2016; 32:72-8. [PMID: 27157827 DOI: 10.1016/j.ejim.2016.03.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is one of the leading causes of cancer mortality in Belgium. In Flanders (Belgium), a population-based screening program with a biennial immunochemical faecal occult blood test (iFOBT) in women and men aged 56-74 has been organised since 2013. This study assessed the cost-effectiveness and budget impact of the colorectal population-based screening program in Flanders (Belgium). METHODS A health economic model was conducted, consisting of a decision tree simulating the screening process and a Markov model, with a time horizon of 20years, simulating natural progression. Predicted mortality and incidence, total costs, and quality-adjusted life-years (QALYs) with and without the screening program were calculated in order to determine the incremental cost-effectiveness ratio of CRC screening. Deterministic and probabilistic sensitivity analyses were conducted, taking into account uncertainty of the model parameters. RESULTS Mortality and incidence were predicted to decrease over 20years. The colorectal screening program in Flanders is found to be cost-effective with an ICER of 1681/QALY (95% CI -1317 to 6601) in males and €4,484/QALY (95% CI -3254 to 18,163). The probability of being cost-effective given a threshold of €35,000/QALY was 100% and 97.3%, respectively. The budget impact analysis showed the extra cost for the health care payer to be limited. CONCLUSION This health economic analysis has shown that despite the possible adverse effects of screening and the extra costs for the health care payer and the patient, the population-based screening program for CRC in Flanders is cost-effective and should therefore be maintained.
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Affiliation(s)
- L Pil
- Faculty of Medicine and Health Sciences, Universiteit Gent, De Pintelaan 185, 9000 Gent, Belgium.
| | - M Fobelets
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium.
| | - K Putman
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium.
| | - J Trybou
- Faculty of Medicine and Health Sciences, Universiteit Gent, De Pintelaan 185, 9000 Gent, Belgium.
| | - L Annemans
- Faculty of Medicine and Health Sciences, Universiteit Gent, De Pintelaan 185, 9000 Gent, Belgium.
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van der Steen A, van Rosmalen J, Kroep S, van Hees F, Steyerberg EW, de Koning HJ, van Ballegooijen M, Lansdorp-Vogelaar I. Calibrating Parameters for Microsimulation Disease Models: A Review and Comparison of Different Goodness-of-Fit Criteria. Med Decis Making 2016; 36:652-65. [PMID: 26957567 DOI: 10.1177/0272989x16636851] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 01/20/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Calibration (estimation of model parameters) compares model outcomes with observed outcomes and explores possible model parameter values to identify the set of values that provides the best fit to the data. The goodness-of-fit (GOF) criterion quantifies the difference between model and observed outcomes. There is no consensus on the most appropriate GOF criterion, because a direct performance comparison of GOF criteria in model calibration is lacking. METHODS We systematically compared the performance of commonly used GOF criteria (sum of squared errors [SSE], Pearson chi-square, and a likelihood-based approach [Poisson and/or binomial deviance functions]) in the calibration of selected parameters of the MISCAN-Colon microsimulation model for colorectal cancer. The performance of each GOF criterion was assessed by comparing the 1) root mean squared prediction error (RMSPE) of the selected parameters, 2) computation time of the calibration procedure of various calibration scenarios, and 3) impact on estimated cost-effectiveness ratios. RESULTS The likelihood-based deviance resulted in the lowest RMSPE in 4 of 6 calibration scenarios and was close to best in the other 2. The SSE had a 25 times higher RMSPE in a scenario with considerable differences in the values of observed outcomes, whereas the Pearson chi-square had a 60 times higher RMSPE in a scenario with multiple studies measuring the same outcome. In all scenarios, the SSE required the most computation time. The likelihood-based approach estimated the cost-effectiveness ratio most accurately (up to -0.15% relative difference versus 0.44% [SSE] and 13% [Pearson chi-square]). CONCLUSIONS The likelihood-based deviance criteria lead to accurate estimation of parameters under various circumstances. These criteria are recommended for calibration in microsimulation disease models in contrast with other commonly used criteria.
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Affiliation(s)
- Alex van der Steen
- Departments of Public Health, Erasmus MC, Rotterdam, The Netherlands (AvdS, SK, FvH, EWS, HJdK, MvB, IL-V)
| | | | - Sonja Kroep
- Departments of Public Health, Erasmus MC, Rotterdam, The Netherlands (AvdS, SK, FvH, EWS, HJdK, MvB, IL-V)
| | - Frank van Hees
- Departments of Public Health, Erasmus MC, Rotterdam, The Netherlands (AvdS, SK, FvH, EWS, HJdK, MvB, IL-V)
| | - Ewout W Steyerberg
- Departments of Public Health, Erasmus MC, Rotterdam, The Netherlands (AvdS, SK, FvH, EWS, HJdK, MvB, IL-V)
| | - Harry J de Koning
- Departments of Public Health, Erasmus MC, Rotterdam, The Netherlands (AvdS, SK, FvH, EWS, HJdK, MvB, IL-V)
| | - Marjolein van Ballegooijen
- Departments of Public Health, Erasmus MC, Rotterdam, The Netherlands (AvdS, SK, FvH, EWS, HJdK, MvB, IL-V)
| | - Iris Lansdorp-Vogelaar
- Departments of Public Health, Erasmus MC, Rotterdam, The Netherlands (AvdS, SK, FvH, EWS, HJdK, MvB, IL-V)
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50
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van Roon AHC, van Dam L, Spaander MC, Lansdorp-Vogelaar I, Dekker E, van Leerdam ME. Different modalities for colorectal cancer screening: experiences in The Netherlands so far. COLORECTAL CANCER 2016. [DOI: 10.2217/crc.2015.0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In 2014, a nation-wide colorectal cancer (CRC) screening program was launched in The Netherlands. Every 2 years, men and women aged 55–75 years will be invited to participate in fecal immunochemical test screening. Participants with a positive test result will be scheduled for colonoscopy. Starting from 2006, screening pilots have been performed to ascertain the choice of an optimal screening modality, population acceptance, logistics and cost effectiveness, in order to ensure that a screening program with maximal benefits and the least amount of harms was offered to the Dutch population. In this overview, we will discuss the results of Dutch CRC screening pilots in which different screening modalities were studied, the preparations made before the launch of the nation-wide screening program, and finally the initial results and lessons learned so far from the Dutch CRC screening program.
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Affiliation(s)
- Aafke HC van Roon
- Department of Gastroenterology & Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Leonie van Dam
- Department of Gastroenterology & Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Manon C Spaander
- Department of Gastroenterology & Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology & Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology & Hepatology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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