Evidence-based decision analysis guiding clinical guidelines for an organized population-based screening for colorectal cancer.
This study includes the long-term benefit-harm analysis of population-wide colorectal cancer (CRC) screening strategies commissioned by the Austrian National Committee for Cancer Screening (ANCCS). In addition, we present the related cost-effectiveness analysis.
Using a validated decision-analytic Markov state transition model, we evaluated 17 by the ANCCS suggested CRC-screening strategies differing in tests (fecal-immunochemical test (FIT), guaiac-based fecal occult blood test (gFOBT), colonoscopy (COL)), age at start (40,45,50 years) and end (COL: 65,70,75 years, FIT/gFOBT 75 years), and intervals (2,5,10 years). Positive FIT/gFOBT tests are followed by colonoscopy. Evaluated outcomes included health benefits (life-years gained (LYG), CRC-cases/CRC-deaths avoided), harms (severe colonoscopy complications, psychological harms due to positive test results (PTR), additional colonoscopies), stepwise evaluated incremental harm-benefit ratios (IHBR), and incremental cost-effectiveness ratios (ICER). We applied the Austrian healthcare system perspective, a lifelong-time horizon and conducted sensitivity analyses.
The most effective colonoscopy-based screening strategy is colonoscopy at age 40/50/60/70 (449 LYG per 1000 individuals) with an IHBR of 3 PTR/LYG compared to COL45/55/65 (ICER: 13,032 Euro/LYG vs. COL45/55/65/75). The most effective fecal blood-test-based strategy is annual FIT testing starting at age 40 years (488 LYG per 1000 individuals) and an IHBR of 30 PTR/LYG compared to FIT40+2y (biennial FIT starting age 40). All biennial FIT-based screening strategies represent alternative options on the harm-benefit efficiency frontier with IHBR of PTR/LYG: 2 (FIT50+2y vs. no screening), 5 (FIT45+2y vs. FIT50+2y), and 7 (FIT40+2y vs. FIT45+2y). The cost-effectiveness analyses provided stepwise ICERs ranging from 3391 Euro/LYG (FIT45+2y vs. FIT50+2y) to 47,812 Euro/LYG (FIT40+1y vs. FIT40+2y).
Our decision analysis shows benefit-harm and cost-effectiveness trade-offs. In the consensus meeting of the ANCCS, colonoscopy- and FIT-based screening starting at age 45 were selected as suggested screening strategies, accounting for benefit-harm balance, evidence level, and implementation aspects.
Using a validated decision-analytic Markov state transition model, we evaluated 17 by the ANCCS suggested CRC-screening strategies differing in tests (fecal-immunochemical test (FIT), guaiac-based fecal occult blood test (gFOBT), colonoscopy (COL)), age at start (40,45,50 years) and end (COL: 65,70,75 years, FIT/gFOBT 75 years), and intervals (2,5,10 years). Positive FIT/gFOBT tests are followed by colonoscopy. Evaluated outcomes included health benefits (life-years gained (LYG), CRC-cases/CRC-deaths avoided), harms (severe colonoscopy complications, psychological harms due to positive test results (PTR), additional colonoscopies), stepwise evaluated incremental harm-benefit ratios (IHBR), and incremental cost-effectiveness ratios (ICER). We applied the Austrian healthcare system perspective, a lifelong-time horizon and conducted sensitivity analyses.
The most effective colonoscopy-based screening strategy is colonoscopy at age 40/50/60/70 (449 LYG per 1000 individuals) with an IHBR of 3 PTR/LYG compared to COL45/55/65 (ICER: 13,032 Euro/LYG vs. COL45/55/65/75). The most effective fecal blood-test-based strategy is annual FIT testing starting at age 40 years (488 LYG per 1000 individuals) and an IHBR of 30 PTR/LYG compared to FIT40+2y (biennial FIT starting age 40). All biennial FIT-based screening strategies represent alternative options on the harm-benefit efficiency frontier with IHBR of PTR/LYG: 2 (FIT50+2y vs. no screening), 5 (FIT45+2y vs. FIT50+2y), and 7 (FIT40+2y vs. FIT45+2y). The cost-effectiveness analyses provided stepwise ICERs ranging from 3391 Euro/LYG (FIT45+2y vs. FIT50+2y) to 47,812 Euro/LYG (FIT40+1y vs. FIT40+2y).
Our decision analysis shows benefit-harm and cost-effectiveness trade-offs. In the consensus meeting of the ANCCS, colonoscopy- and FIT-based screening starting at age 45 were selected as suggested screening strategies, accounting for benefit-harm balance, evidence level, and implementation aspects.
Authors
Jahn Jahn, Sroczynski Sroczynski, Santamaria Santamaria, Rochau Rochau, Siebert Siebert, Mühlberger Mühlberger, Puntscher Puntscher, Ferlitsch Ferlitsch, Hackl Hackl, Tilg Tilg, Renner Renner, Gschwantler Gschwantler, Schiller-Fruehwirth Schiller-Fruehwirth, Fischer Fischer, Bachler Bachler, Fröschl Fröschl, Dietscher Dietscher, Schernhammer Schernhammer, Gartlehner Gartlehner, Siebert Siebert,
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