Ann G. Zauber, PhD; Iris Lansdorp-Vogelaar, MS; Amy B. Knudsen, PhD; Janneke Wilschut, MS; Marjolein van Ballegooijen, MD, PhD; Karen M. Kuntz, ScD
Acknowledgment: The authors thank the following for helpful comments and review of earlier versions of this paper: Mary Barton, MD, MPH, and William Lawrence, MD, MSc, of the Agency for Healthcare Research and Quality; Steve Teutsch, MD, Diana Petitti, MD, Michael Lefevre, MD, and George Isham, MD, of the U.S. Preventive Services Task Force; Eric (Rocky) Feuer, PhD, of the National Cancer Institute; Evelyn Whitlock, PhD, of the Oregon Evidence-based Practice Center; and the outside reviewers: Laura Seeff, MD, David Ransohoff, MD, and Carolyn Rutter, PhD.
Grant Support: By the National Cancer Institute (U01-CA-088204, U01-CA-097426, and U01-CA-115953) and the Agency for Healthcare Research and Quality (HHSP233200700350P, HHSP233200700210P, and HHSP233200700196P).
Potential Financial Conflicts of Interest: None disclosed.
Corresponding Author: Ann G. Zauber, PhD, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, 307 East 63rd Street, New York, NY 10065; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Zauber: Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, 307 East 63rd Street, New York, NY 10065.
Ms. Lansdorp-Vogelaar, Ms. Wilschut, and Dr. van Ballegooijen: Erasmus Medical Center, Dr. Molewaterplein 50, Rotterdam 3000CA, the Netherlands.
Dr. Knudsen: Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114.
Dr. Kuntz: University of Minnesota, Division of Health Policy and Management, MMC 729 Mayo, 15-232 PWB, 516 Delaware Street Southeast, Minneapolis, MN 55455.
The U.S. Preventive Services Task Force requested a decision analysis to inform their update of recommendations for colorectal cancer screening.
To assess life-years gained and colonoscopy requirements for colorectal cancer screening strategies and identify a set of recommendable screening strategies.
Decision analysis using 2 colorectal cancer microsimulation models from the Cancer Intervention and Surveillance Modeling Network.
Derived from the literature.
U.S. average-risk 40-year-old population.
Fecal occult blood tests (FOBTs), flexible sigmoidoscopy, or colonoscopy screening beginning at age 40, 50, or 60 years and stopping at age 75 or 85 years, with screening intervals of 1, 2, or 3 years for FOBT and 5, 10, or 20 years for sigmoidoscopy and colonoscopy.
Number of life-years gained compared with no screening and number of colonoscopies and noncolonoscopy tests required.
Beginning screening at age 50 years was consistently better than at age 60. Decreasing the stop age from 85 to 75 years decreased life-years gained by 1% to 4%, whereas colonoscopy use decreased by 4% to 15%. Assuming equally high adherence, 4 strategies provided similar life-years gained: colonoscopy every 10 years, annual Hemoccult SENSA (Beckman Coulter, Fullerton, California) testing or fecal immunochemical testing, and sigmoidoscopy every 5 years with midinterval Hemoccult SENSA testing. Annual Hemoccult II and flexible sigmoidoscopy every 5 years alone were less effective.
The results were most sensitive to beginning screening at age 40 years.
The stop age for screening was based only on chronologic age.
The findings support colorectal cancer screening with the following: colonoscopy every 10 years, annual screening with a sensitive FOBT, or flexible sigmoidoscopy every 5 years with a midinterval sensitive FOBT from age 50 to 75 years.
Natural history of disease as modeled by the Microsimulation Screening Analysis and Simulation Model of Colorectal Cancer models.
The opportunity to intervene in the natural history through screening is noted.
Table 1. Comparison of the Natural History Outcomes from the Microsimulation Screening Analysis (MISCAN) and Simulation Model of Colorectal Cancer (SimCRC) Models
Table 2. Test Characteristics Used in the Microsimulation Screening Analysis and Simulation Model of Colorectal Cancer Models
Table 3. Efficient and Near-Efficient Strategies for Colonoscopy Screening
Appendix Table. Efficient and Near-Efficient Strategies
Colonoscopies and life-years gained (compared with no screening) for a cohort of 1000 forty-year-olds for 18 colonoscopy screening strategies that vary by start age, stop age, and screening interval.
The numbers represent the following: age to beginage to stop screening, interval. MISCAN= Microsimulation Screening Analysis; SimCRC= Simulation Model of Colorectal Cancer.
Table 4. Outcomes for the Recommendable Set of Efficient Screening Strategies
Colonoscopies and life-years gained, by adherence level for the recommendable set of screening strategies.
SENSA= Hemoccult SENSA; FIT= fecal immunochemical testing; FSIG= flexible sigmoidoscopy; MISCAN= Microsimulation Analysis Model; SimCRC= Simulation Model of Colorectal Cancer. *The numbers represent the following: age to beginage to stop screening, interval.
Microsimulation Screening Analysis and Simulation Model of Colorectal Cancer modeling of natural history into life history.
Microsimulation Screening Analysis and Simulation Model of Colorectal Cancer modeling of screening into life history.
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Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, van Ballegooijen M, Kuntz KM. Evaluating Test Strategies for Colorectal Cancer Screening: A Decision Analysis for the U.S. Preventive Services Task Force. Ann Intern Med. ;149:659–669. doi: 10.7326/0003-4819-149-9-200811040-00244
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Published: Ann Intern Med. 2008;149(9):659-669.
Cancer Screening/Prevention, Colorectal Cancer, Gastroenterology/Hepatology, Gastrointestinal Cancer, Guidelines.
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