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Original Research |

Rescreening of Persons With a Negative Colonoscopy Result: Results From a Microsimulation Model

Amy B. Knudsen, PhD; Chin Hur, MD, MPH; G. Scott Gazelle, MD, MPH, PhD; Deborah Schrag, MD, MPH; Elizabeth G. McFarland, MD; and Karen M. Kuntz, ScD
[+] Article and Author Information

From Massachusetts General Hospital, Harvard School of Public Health, and Dana-Farber Cancer Institute, Boston, Massachusetts; SSM St. Joseph Hospital, St. Charles, Missouri; and School of Public Health, University of Minnesota, Minneapolis, Minnesota.

Acknowledgment: The authors thank Martin Brown, PhD, and Robin Yabroff, PhD, of the National Cancer Institute for their assistance in obtaining colorectal cancer treatment costs using SEER–Medicare linked data and Eric (Rocky) Feuer, PhD, of the National Cancer Institute for continued support of the work and infrastructure of the CISNET consortium. They also thank Carolyn M. Rutter, PhD, of the Group Health Research Institute and Ann G. Zauber, PhD, of Memorial Sloan-Kettering Cancer Center for helpful comments and review of earlier versions of this article. None of these persons received compensation for their contributions.

Grant Support: By award RC1CA147256 and grants U01CA088204 and U01CA152959 from the National Cancer Institute, National Institutes of Health.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0742.

Reproducible Research Statement: Study protocol: Available from Dr. Knudsen (e-mail, aknudsen@mgh-ita.org). Statistical code and data set: Simulation model available from Dr. Knudsen.

Requests for Single Reprints: Amy B. Knudsen, PhD, Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac Street, 10th Floor, Boston, MA 02114; e-mail, aknudsen@mgh-ita.org.

Current Author Addresses: Drs. Knudsen, Hur, and Gazelle: Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac Street, 10th Floor, Boston, MA 02114.

Dr. Schrag: Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215.

Dr. McFarland: SSM St. Joseph Medical Center, 300 First Capitol Drive, St. Charles, MO 63301.

Dr. Kuntz: Division of Health Policy and Management, School of Public Health, University of Minnesota, MMC 729, 420 Delaware Street Southeast, Minneapolis, MN 55455.

Author Contributions: Conception and design: A.B. Knudsen, C. Hur, G.S. Gazelle, K.M. Kuntz.

Analysis and interpretation of the data: A.B. Knudsen, C. Hur, G.S. Gazelle, D. Schrag, E.G. McFarland, K.M. Kuntz.

Drafting of the article: A.B. Knudsen, C. Hur, G.S. Gazelle, D. Schrag, E.G. McFarland.

Critical revision of the article for important intellectual content: A.B. Knudsen, C. Hur, G.S. Gazelle, D. Schrag, E.G. McFarland, K.M. Kuntz.

Final approval of the article: A.B. Knudsen, C. Hur, G.S. Gazelle, D. Schrag, E.G. McFarland, K.M. Kuntz.

Provision of study materials or patients: G.S. Gazelle.

Statistical expertise: C. Hur, G.S. Gazelle, D. Schrag, K.M. Kuntz.

Obtaining of funding: A.B. Knudsen, G.S. Gazelle.

Administrative, technical, or logistic support: G.S. Gazelle, D. Schrag.

Collection and assembly of data: A.B. Knudsen, G.S. Gazelle, D. Schrag.


Ann Intern Med. 2012;157(9):611-620. doi:10.7326/0003-4819-157-9-201211060-00005
Text Size: A A A

Background: Persons with a negative result on screening colonoscopy are recommended to repeat the procedure in 10 years.

Objective: To assess the effectiveness and costs of colonoscopy versus other rescreening strategies after an initial negative colonoscopy result.

Design: Microsimulation model.

Data Sources: Literature and data from the Surveillance, Epidemiology, and End Results program.

Target Population: Persons aged 50 years who had no adenomas or cancer detected on screening colonoscopy.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: No further screening or rescreening starting at age 60 years with colonoscopy every 10 years, annual highly sensitive guaiac fecal occult blood testing (HSFOBT), annual fecal immunochemical testing (FIT), or computed tomographic colonography (CTC) every 5 years.

Outcome Measures: Lifetime cases of colorectal cancer, life expectancy, and lifetime costs per 1000 persons, assuming either perfect or imperfect adherence.

Results of Base-Case Analysis: Rescreening with any method substantially reduced the risk for colorectal cancer compared with no further screening (range, 7.7 to 12.6 lifetime cases per 1000 persons [perfect adherence] and 17.7 to 20.9 lifetime cases per 1000 persons [imperfect adherence] vs. 31.3 lifetime cases per 1000 persons with no further screening). In both adherence scenarios, the differences in life-years across rescreening strategies were small (range, 30 893 to 30 902 life-years per 1000 persons [perfect adherence] vs. 30 865 to 30 869 life-years per 1000 persons [imperfect adherence]). Rescreening with HSFOBT, FIT, or CTC had fewer complications and was less costly than continuing colonoscopy.

Results of Sensitivity Analysis: Results were sensitive to test-specific adherence rates.

Limitation: Data on adherence to rescreening were limited.

Conclusion: Compared with the currently recommended strategy of continuing colonoscopy every 10 years after an initial negative examination, rescreening at age 60 years with annual HSFOBT, annual FIT, or CTC every 5 years provides approximately the same benefit in life-years with fewer complications at a lower cost. Therefore, it is reasonable to use other methods to rescreen persons with negative colonoscopy results.

Primary Funding Source: National Cancer Institute.

Figures

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Figure 1.

The Simulation Model of Colorectal Cancer natural history model (solid lines) with the effect of screening noted (dotted lines).

For a brief description of the model, see the Methods section.

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Appendix Figure 1.

Sensitivity analysis on the unit cost of a colonoscopy, assuming perfect (top) or imperfect (bottom) adherence.

Lifetime costs of rescreening strategies for persons with a negative screening colonoscopy result at age 50 years. COL = colonoscopy; CTC = computed tomographic colonography with ≥6-mm threshold for colonoscopy referral; FIT = fecal immunochemical test; HSFOBT = highly sensitive guaiac fecal occult blood test.

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Appendix Figure 2.

Sensitivity analysis on the costs of cancer care, assuming perfect (top) or imperfect (bottom) adherence.

Lifetime cost savings from using methods other than colonoscopy every 10 y. COL = colonoscopy; CTC = computed tomographic colonography with ≥6-mm threshold for colonoscopy referral; FIT = fecal immunochemical test; HSFOBT = highly sensitive guaiac fecal occult blood test.

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Figure 2.

Life-years (top) and lifetime costs (bottom) per 1000 persons aged 50 years with a negative screening colonoscopy result and imperfect adherence.

Appendix Table 1 provides the assumptions for the sensitivity analysis on adherence rates. COL = colonoscopy; CTC = computed tomographic colonography with ≥6-mm threshold for colonoscopy referral; FIT = fecal immunochemical test; HSFOBT = highly sensitive guaiac fecal occult blood test.

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