Background The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for colorectal cancer (CRC) in adequately screened elderly aged over 75. The USPSTF did not address the appropriateness of screening in elderly aged over 75 without prior screening. Objective To determine up to what age CRC screening should be considered in unscreened elderly with no, moderate, and severe comorbidity and to determine which test is indicated at what age. Design Microsimulation modeling study. Data Sources Derived from the literature. Target Populations Unscreened elderly aged 76, 77, (...), and 90 with no, moderate, and severe comorbidity. Time Horizon Lifetime. Perspective Societal. Interventions Once-only colonoscopy, sigmoidoscopy, and fecal immunochemical test (FIT) screening. Outcome Measures CRC cases prevented, CRC deaths prevented, life-years gained, quality-adjusted life-years (QALYs) gained, costs, and costs per QALY gained. Results of Base-Case Analysis In unscreened elderly with no, moderate, and severe comorbidity, CRC screening was cost-effective up to age 86, 83, and 80, respectively. In unscreened elderly with no comorbidity, colonoscopy screening was most effective and still cost-effective up to age 83; sigmoidoscopy screening was indicated at age 84; and FIT screening was indicated at ages 85 and 86. In unscreened elderly with moderate (severe) comorbidity, colonoscopy screening was indicated up to age 80 (77); sigmoidoscopy screening was indicated at age 81 (78); and FIT screening was indicated at ages 82 and 83 (79 and 80). Results of Sensitivity Analyses Results were most sensitive to lowering the threshold for the willingness-to-pay per QALY gained from $100,000 to $50,000. Limitation We only considered cohorts at average risk for CRC. Conclusions In unscreened elderly with no, moderate, and severe comorbidity, whose physical condition allows a colonoscopy, CRC screening should be considered well beyond age 75: up to age 86, 83, and 80, respectively. At most ages, colonoscopy screening is indicated. Primary Funding Source The U.S. National Cancer Institute.
A comparison is made between the outcome distributions of two Dutch series of patients with severe head injuries. Both series are taken from the same study and cover the same period (1974 to 1977). There is a large difference in survival rate between the series: 45% versus 63%. The authors present a possible method for assessing the influence of differences in initial severity of injury on outcome. It is estimated that, of the 18% difference in survival rate, 10.5% is due to differences in severity of injury on admission. The remaining 7.5% difference in survival rate is not explained, but may have been caused by unmeasured variations in the initial determination of severity of injury or by differences in effectiveness of management. The higher survival rate was achieved at the center with the more conservative management regimen. An evaluation of recent literature suggests that reports that do not find aspects of "aggressive" management beneficial are more reliable in comparing series than are those that claim improved outcome after aggressive therapy.
Summary The pattern of spontaneous screening for cervical cancer by general practitioners and gynaecologists in The Netherlands is compared with an efficient screening policy resulting from a cost-effective study. Spontaneous screening tends to start and stop too early in a woman's life, and leaves too many women overscreened or unprotected. The combination in young age of a low incidence of invasive cancer and a high incidence of regressive lesions explains relative ineffectiveness and harmfulness of present screening practice. When screening would take place between ages 30 and at least 60, with intervals of about 5 years, as many lives could be saved for half the costs and with only 60% of the unnecessary referrals and treatments. Much attention should be paid to the coverage of the target population. Therapeutic follow-up policies for dysplastic lesions should be restrained.Screening has contributed to the decrease in cervical cancer mortality in several countries (Day 1986a, Hakama, 1985Laara et al., 1987;Day, 1984;van der Graaf et al., 1988). There is still debate on the age to start screening and on the interval. Some screening recommendations call for intensive screening at a young age (ACOG, 1980; CTF, 1982) but studies which analyse the health effects of screening conclude that screening efforts should be directed to middle aged and older women (Liiara et al., 1987;Knox, 1976;Miller, 1985;Day, 1986b;Parkin et al., 1986). The advocated interval has been lengthening the last few years but in practice the interval tends to be still short.The pros and cons of screening policies critically depend on the duration and detectability of the preclinical stages of the disease. Knowledge of these important parameters can be derived from the results of existing screening programmes. Therefore, a detailed analysis was made of data from the early detection programmes in British Columbia and in The Netherlands. Both analyses led to very similar conclusions (Habbema et al., 1985). The first one has been published recently in this journal (van Oortmarssen, 1991).In this article we study the consequences of the results on duration and regression for balanced Pap-smear taking. We compare spontaneous screening with optimised screening, studying the costs, risks and benefits. Methods and materialsThe natural history For The Netherlands, the following estimates were derived: -a smear will detect 70% of the cases of cervical intraepithelial neoplasia (CIN) III (sensitivity, that pertains to the situation in which women with at least (cytologically) moderate dysplasia twice or severe dysplasia once are referred for colposcopy); -0.4% of the smears will be false-positive (no CIN, or at the most CIN II will be found histologically).the mean duration of CIN III is 15 years; -on average 60% of the cases of CIN III will regress spontaneously, this percentage is highest at younger age (see Figure 1); -a higher incidence of cervical cancer in non-attenders to screening than in attenders. Predictive calculationsThe assumptions on nat...
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