Amnon Sonnenberg, MD, MSc; Fabiola Delcò, MD, MPH; John M. Inadomi, MD
Fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy are used to screen patients for colorectal cancer.
To compare the cost-effectiveness of fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy.
The cost-effectiveness of the three screening strategies was compared by using computer models of a Markov process. In the model, a hypothetical population of 100 000 persons 50 years of age undergoes annual fecal occult blood testing, sigmoidoscopy every 5 years, or colonoscopy every 10 years. Positive results on fecal occult blood testing or adenomatous polyps found during sigmoidoscopy are worked up by using colonoscopy. After polypectomy, colonoscopy is repeated every 3 years until no polyps are found.
Transition rates were estimated from U.S. vital statistics and cancer statistics and from published data on the sensitivity, specificity, and efficacy of various screening techniques. Costs of screening and cancer care were estimated from Medicare reimbursement data.
Persons 50 years of age in the general population.
The study population was followed annually until death.
Incremental cost-effectiveness ratio.
Compared with colonoscopy, annual screening with fecal occult blood testing costs less but saves fewer life-years. A screening strategy based on flexible sigmoidoscopy every 5 or 10 years is less cost-effective than the other two screening methods.
Screening with fecal occult blood testing is more sensitive to changes in compliance rates, and it becomes easily dominated by colonoscopy under most conditions assuming less than perfect compliance. Other assumptions about the sensitivity and specificity of fecal occult blood testing, screening frequency, efficacy of colonoscopy in preventing cancer, and polyp incidence have a lesser influence on the differences in cost-effectiveness between colonoscopy and fecal occult blood testing.
Colonoscopy represents a cost-effective means of screening for colorectal cancer because it reduces mortality at relatively low incremental costs. Low compliance rates render colonoscopy every 10 years the most cost-effective primary screening strategy for colorectal cancer.
Costs Based on Medicare Payments in 2000
Outcome of Screening Programs To Prevent Colorectal Cancer
Incremental Cost-Effectiveness Ratios
Appendix Table. Baseline Assumptions and Ranges Tested in the Sensitivity Analysis
The black and gray ovals represent Markov states in which patients remain for at least a full 1-year cycle. The white ovals represent intermediate states of screening procedures, which patients may enter and leave during one cycle. The arrows represent transitions between various states.
From the Department of Veterans Affairs Medical Center and the University of New Mexico, Albuquerque, New Mexico.
Grant Support: By the Centers for Disease Control and Prevention (Dr. Sonnenberg), the Swiss Foundation for Grants in Medicine and Biology (Dr. Delcò), and an American College of Gastroenterology Faculty Development Award (Dr. Inadomi).
Requests for Single Reprints: Amnon Sonnenberg, MD, MSc, Department of Veterans Affairs Medical Center 111F, 1501 San Pedro Drive SE, Albuquerque, NM 87108.
Current Author Addresses: Dr. Sonnenberg; Department of Veterans Affairs Medical Center 111F, 1501 San Pedro Drive SE, Albuquerque, NM 87108.
Dr. Delcò: Gastroenterologie, Kantonsspital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
Dr. Inadomi: Department of Veterans Affairs Medical Center 111D, 2215 Fuller Road, Ann Arbor, MI 48105.
Author Contributions: Conception and design: A. Sonnenberg, F. Delcò, J.M. Inadomi.
Analysis and interpretation of the data: A. Sonnenberg, F. Delcò, J.M. Inadomi.
Drafting of the article: A. Sonnenberg, F. Delcò.
Critical revision of the article for important intellectual content: A. Sonnenberg, F. Delcò, J.M. Inadomi.
Final approval of the article: A. Sonnenberg, F. Delcò, J.M. Inadomi.
Provision of study materials or patients: A. Sonnenberg, F. Delcò.
Statistical expertise: A. Sonnenberg, J.M. Inadomi.
Obtaining of funding: A. Sonnenberg.
Administrative, technical, or logistic support: A. Sonnenberg.
Collection and assembly of data: A. Sonnenberg, F. Delcò.
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Amnon Sonnenberg, Fabiola Delcò, John M. Inadomi. Cost-Effectiveness of Colonoscopy in Screening for Colorectal Cancer. Ann Intern Med. 2000;133:573–584. doi: 10.7326/0003-4819-133-8-200010170-00007
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Published: Ann Intern Med. 2000;133(8):573-584.
Cancer Screening/Prevention, Colonoscopy/Sigmoidoscopy, Colorectal Cancer, Gastroenterology/Hepatology, Gastrointestinal Cancer.
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