Estimation of Benefits, Burden, and Harms of Colorectal Cancer Screening Strategies

Abstract

IMPORTANCEThe US Preventive Services Task Force (USPSTF) is updating its 2008 colorectal cancer (CRC) screening recommendations.OBJECTIVE To inform the USPSTF by modeling the benefits, burden, and harms of CRC screening strategies; estimating the optimal ages to begin and end screening; and identifying a set of model-recommendable strategies that provide similar life-years gained (LYG) and a comparable balance between LYG and screening burden. DESIGN, SETTING, AND PARTICIPANTSComparative modeling with 3 microsimulation models of a hypothetical cohort of previously unscreened US 40-year-olds with no prior CRC diagnosis.EXPOSURES Screening with sensitive guaiac-based fecal occult blood testing, fecal immunochemical testing (FIT), multitarget stool DNA testing, flexible sigmoidoscopy with or without stool testing, computed tomographic colonography (CTC), or colonoscopy starting at age 45, 50, or 55 years and ending at age 75, 80, or 85 years. Screening intervals varied by modality. Full adherence for all strategies was assumed. MAIN OUTCOMES AND MEASURESLife-years gained compared with no screening (benefit), lifetime number of colonoscopies required (burden), lifetime number of colonoscopy complications (harms), and ratios of incremental burden and benefit (efficiency ratios) per 1000 40-year-olds. RESULTSThe screening strategies provided LYG in the range of 152 to 313 per 1000 40-year-olds. Lifetime colonoscopy burden per 1000 persons ranged from fewer than 900 (FIT every 3 years from ages 55-75 years) to more than 7500 (colonoscopy screening every 5 years from ages 45-85 years). Harm from screening was at most 23 complications per 1000 persons screened. Strategies with screening beginning at age 50 years generally provided more LYG as well as more additional LYG per additional colonoscopy than strategies with screening beginning at age 55 years. There were limited empirical data to support a start age of 45 years. For persons adequately screened up to age 75 years, additional screening yielded small increases in LYG relative to the increase in colonoscopy burden. With screening from ages 50 to 75 years, 4 strategies yielded a comparable balance of screening burden and similar LYG (median LYG per 1000 across the models): colonoscopy every 10 years (270 LYG); sigmoidoscopy every 10 years with annual FIT (256 LYG); CTC every 5 years (248 LYG); and annual FIT (244 LYG). CONCLUSIONS AND RELEVANCEIn this microsimulation modeling study of a previously unscreened population undergoing CRC screening that assumed 100% adherence, the strategies of colonoscopy every 10 years, annual FIT, sigmoidoscopy every 10 years with annual FIT, and CTC every 5 years performed from ages 50 through 75 years provided similar LYG and a comparable balance of benefit and screening burden.

Value Of Waiving Coinsurance For Colorectal Cancer Screening In Medicare Beneficiaries

“…MISCAN-Colon was developed by the Department of Public Health within Erasmus University Medical Center, Rotterdam, the Netherlands, and has been described extensively elsewhere (15, 16). It is part of the US National Cancer Institute’s (NCI’s) Cancer intervention and Surveillance Modeling Network (CISNET) (17) and has been used to inform screening recommendations of the USPSTF (18, 19). In brief, the model generates, with random variation, the individual life histories for a large cohort to simulate the US population in terms of life expectancy and cancer risk.…”

“…Detected adenomas were removed and followed by colonoscopy surveillance every 3–5 years depending on the number and the size of adenomas detected as recommended by current guidelines (21). Test characteristics were based on a study by Knudsen et al (19). We assumed a FIT reimbursement of US $21.65 (22).…”

Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer

“…Several trials are ongoing, but results are not yet available. When compared using simulation models that are dependent on assumptions about natural history of disease, patient acceptance of screening, and test performance, several tests appear to be similarly eff ective ( 121 ). Th erefore, practical considerations are important for informing our recommendations.…”

Racial Disparity in Gastrointestinal Cancer Risk

“…Several strategies have recently been outlined [105] to decrease the CRC disparity among Blacks, including: (a) improve patient education to reduce patient-level barriers to screening, (b) improve provider education for increasing recommendations for screening in Blacks, (c) implement patient navigation, which is cost-effective in increasing colonoscopic screening among Blacks, (d) increase the overall CRC screening rates among Blacks to be on par with screening rates for NHWs, and (e) modify the age of screening in Blacks due to the differences in observed biology, and which have been recommended by several organizations [4,75,105] and most recently by the 2017 U.S. Multi-Society Task Force on Colorectal Cancer recommendations [64]. The US Preventive Services Task Force recommends screening average risk persons at age 50 years of age, but recognizes CRC disparities and endorses efforts to ensure that specific populations at risk receive recommended screening and follow up [106]. Based on the higher incidence of proximal CRCs among Blacks, colonoscopy is preferred per ACG recommendations [75].…”