Michael Pignone, MD, MPH; Somnath Saha, MD, MPH; Tom Hoerger, PhD; Jeanne Mandelblatt, MD, MPH
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position from the U. S. Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Acknowledgments: The authors thank the following persons for support and assistance: Mark Helfand, MD, MPH, and Kathryn Krages, AMLS, MA, Oregon Health and Science University Evidence-based Practice Center; Carol Krasnov, Research Triangle Institute–University of North Carolina Evidence-based Practice Center; Martin Brown, PhD, National Cancer Institute; and David Atkins, MD, MPH, and Eve Shapiro, Agency for Healthcare Research and Quality.
Grant Support: By contract 290-97-0011 from the Agency for Healthcare Research and Quality. Dr. Pignone's work was partially supported by an American Cancer Society Career Development Award. Dr. Saha's work was supported by a career development award from the Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. Dr. Mandelblatt's work on this project was partially supported by contract U01CA88283A and grant CA 72908 from the National Cancer Institute and grant CA 74187 from the National Institute on Aging.
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Current Author Addresses: Dr. Pignone: Department of Medicine, Division of General Internal Medicine, University of North Carolina, 5039 Old Clinic Building 226, CB 7110, Chapel Hill, NC 27599.
Dr. Saha: Section of General Internal Medicine, Portland Veterans Affairs Medical Center, Division of Medical Informatics and Outcomes Research, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098.
Dr. Hoerger: Research Triangle Institute, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709-2194.
Dr. Mandelblatt: Cancer Control, Lombardi Cancer Center, Georgetown University Medical Center, 223 Wisconsin Avenue, Suite 430, Washington, DC 20007.
Author Contributions: Conception and design: M. Pignone, S. Saha, T. Hoerger.
Analysis and interpretation of the data: M. Pignone, S. Saha, T. Hoerger, J. Mandelblatt.
Drafting of the article: M. Pignone, S. Saha.
Critical revision of the article for important intellectual content: M. Pignone, S. Saha, T. Hoerger, J. Mandelblatt.
Final approval of the article: M. Pignone, S. Saha, J. Mandelblatt.
Provision of study materials or patients: S. Saha.
Statistical expertise: M. Pignone, T. Hoerger.
Obtaining of funding: J. Mandelblatt.
Administrative, technical, or logistic support: M. Pignone, T. Hoerger, J. Mandelblatt.
Collection and assembly of data: M. Pignone, T. Hoerger.
To perform a systematic review of the cost-effectiveness of colorectal cancer screening for the U.S. Preventive Services Task Force.
MEDLINE and the British National Health Service Economic Evaluation Database, January 1993 through September 2001.
Original economic evaluations of colorectal cancer screening in average-risk patients were reviewed. The authors sought studies addressing the incremental cost-effectiveness of different screening strategies compared with no screening, of different screening strategies compared with one another, and of different ages of screening initiation and cessation. Two investigators independently reviewed each abstract, and potentially eligible articles were retrieved. A four-member working group reached consensus regarding final inclusion or exclusion of articles.
One reviewer extracted data into evidence tables. The results were checked by other members and discrepancies resolved by consensus.
Among 180 potential articles identified, 7 were retained in the final analysis. Compared with no screening, cost-effectiveness ratios for screening with any of the commonly considered methods were generally between $10 000 and $25 000 per life-year saved. No one strategy was consistently found to be the most effective or to have the best incremental cost-effectiveness ratio. Currently available models provided insufficient evidence to determine optimal starting and stopping ages for screening.
Screening for colorectal cancer appears cost-effective compared with no screening, but a single optimal strategy cannot be determined from the currently available data. Additional data regarding adherence with screening over time, complication rates in real-world settings, and colorectal cancer biology are needed. Additional analyses are necessary to determine optimal ages of initiation and cessation.
It is unclear which colorectal cancer screening strategy is most cost-effective.
On behalf of the U.S. Preventive Services Task Force, the authors reviewed seven published analyses that addressed the cost-effectiveness of fecal occult blood testing (single or annual), flexible sigmoidoscopy every 5 years alone or with fetal occult blood testing, barium enema every 5 years, and colonoscopy every 10 years.
The screening strategies all cost $10 000 to $25 000 per year of life saved.
Physicians should discuss the advantages and disadvantages of the various colorectal cancer screening strategies with their patients to decide which test is best for each individual.
What is the cost-effectiveness of colorectal cancer screening by any method compared with no screening?
Can we use incremental cost-effectiveness data to determine the relative effectiveness and cost-effectiveness of different screening options and thus determine whether there is a preferred strategy for screening?
What is the incremental cost-effectiveness of continuing screening to 85 years of age compared with stopping screening at 70, 75, or 80 years of age? What is the incremental cost-effectiveness of starting screening at 40 or 45 years of age compared with 50 years of age?
Table 1. Study Characteristics
Table 2. Cost-Effectiveness Ratios of Various Tests for Colorectal Cancer Compared with No Screening
Table 3. Preferred Strategy at Different Levels of “Acceptable” Costs per Life-Year Saved
Appendix Table 1. Excluded Articles
Appendix Table 2. Calculated Incremental Cost-Effectiveness Ratios from Five Major Cost-Effectiveness Analyses
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Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-Effectiveness Analyses of Colorectal Cancer Screening: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:96-104. doi: 10.7326/0003-4819-137-2-200207160-00007
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Published: Ann Intern Med. 2002;137(2):96-104.
Cancer Screening/Prevention, Colorectal Cancer, Gastroenterology/Hepatology, Gastrointestinal Cancer, Healthcare Delivery and Policy.
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