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Original Research |

Should Colorectal Cancer Screening Be Considered in Elderly Persons Without Previous Screening?: A Cost-Effectiveness AnalysisColorectal Cancer Screening in Unscreened Elderly Persons

Frank van Hees, MSc; J. Dik F. Habbema, PhD; Reinier G. Meester, MSc; Iris Lansdorp-Vogelaar, PhD; Marjolein van Ballegooijen, MD, PhD*; and Ann G. Zauber, PhD*
[+] Article and Author Information

*Drs. van Ballegooijen and Zauber contributed equally as co–senior authors.


From Erasmus University Medical Center, Rotterdam, the Netherlands, and Memorial Sloan Kettering Cancer Center, New York, New York.

Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute.

Grant Support: By the National Cancer Institute (grant U01-CA152959) as part of the Cancer Intervention and Surveillance Modeling Network.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2263.

Reproducible Research Statement: Study protocol, statistical code, and data set: Available from Mr. van Hees (e-mail, f.vanhees@erasmusmc.nl).

Requests for Single Reprints: Frank van Hees, MSc, Department of Public Health, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands; e-mail, f.vanhees@erasmusmc.nl.

Current Author Addresses: Mr. van Hees; Drs. Habbema, Lansdorp-Vogelaar, and van Ballegooijen; and Mr. Meester: Department of Public Health, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands.

Dr. Zauber: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065.

Author Contributions: Conception and design: F. van Hees, J.D.F. Habbema, I. Lansdorp-Vogelaar, M. van Ballegooijen, A.G. Zauber.

Analysis and interpretation of the data: F. van Hees, J.D.F. Habbema, R.G. Meester, I. Lansdorp-Vogelaar, M. van Ballegooijen, A.G. Zauber.

Drafting of the article: F. van Hees, A.G. Zauber.

Critical revision of the article for important intellectual content: F. van Hees, J.D.F. Habbema, R.G. Meester, I. Lansdorp-Vogelaar, M. van Ballegooijen, A.G. Zauber.

Final approval of the article: F. van Hees, J.D.F. Habbema, R.G. Meester, I. Lansdorp-Vogelaar, M. van Ballegooijen, A.G. Zauber.

Statistical expertise: J.D.F. Habbema, I. Lansdorp-Vogelaar, A.G. Zauber.

Obtaining of funding: I. Lansdorp-Vogelaar, M. van Ballegooijen, A.G. Zauber.

Administrative, technical, or logistic support: A.G. Zauber.

Collection and assembly of data: F. van Hees.


Ann Intern Med. 2014;160(11):750-759. doi:10.7326/M13-2263
Text Size: A A A

Background: The U.S. Preventive Services Task Force recommends against routine screening for colorectal cancer (CRC) in adequately screened persons older than 75 years but does not address the appropriateness of screening in elderly persons without previous screening.

Objective: To determine at what ages CRC screening should be considered in unscreened elderly persons and to determine which test is indicated at each age.

Design: Microsimulation modeling study.

Data Sources: Observational and experimental studies.

Target Population: Unscreened persons aged 76 to 90 years with no, moderate, and severe comorbid conditions.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: One-time colonoscopy, sigmoidoscopy, or fecal immunochemical test (FIT) screening.

Outcome Measures: Quality-adjusted life-years gained, costs, and costs per quality-adjusted life-year gained.

Results of Base-Case Analysis: In unscreened elderly persons with no comorbid conditions, CRC screening was cost-effective up to age 86 years. Screening with colonoscopy was indicated up to age 83 years, sigmoidoscopy was indicated at age 84 years, and FIT was indicated at ages 85 and 86 years. In unscreened persons with moderate comorbid conditions, screening was cost-effective up to age 83 years (colonoscopy indicated up to age 80 years, sigmoidoscopy at age 81 years, and FIT at ages 82 and 83 years). In unscreened persons with severe comorbid conditions, screening was cost-effective up to age 80 years (colonoscopy indicated up to age 77 years, sigmoidoscopy at age 78 years, and FIT at ages 79 and 80 years).

Results of Sensitivity Analyses: Results were most sensitive to assuming a lower willingness to pay per quality-adjusted life-year gained.

Limitation: Only persons at average risk for CRC were considered.

Conclusion: In unscreened elderly persons CRC screening should be considered well beyond age 75 years. A colonoscopy is indicated at most ages.

Primary Funding Source: National Cancer Institute.

Figures

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Figure 1.

Cost-effectiveness of 1-time colonoscopy, sigmoidoscopy, and FIT screening compared with no screening in elderly persons without previous screening with no, moderate, and severe comorbid conditions.

Results are presented per 1000 persons and discounted by 3% per year. Persons are classified as having moderate comorbid conditions if they have an ulcer, rheumatologic disease, peripheral vascular disease, diabetes, paralysis, cerebrovascular disease, or a history of acute myocardial infarction; severe comorbid conditions if they have chronic obstructive pulmonary disease, congestive heart failure, moderate or severe liver disease, chronic renal failure, dementia, cirrhosis and chronic hepatitis, or AIDS; and no comorbid conditions if none of these conditions are present. The dashed line indicates a willingness to pay per QALY gained of $100 000. Screening strategies costing less than $100 000 per QALY gained are considered cost-effective. Asterisks for missing screening strategies indicate that they were associated with a net health loss rather than a benefit (Appendix Table 3 and Table 2). FIT = fecal immunochemical test; QALY = quality-adjusted life-year.

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Figure 2.

The incremental cost-effectiveness of the efficient screening strategies in elderly persons without previous screening with no, moderate, and severe comorbid conditions.

Results are presented per 1000 persons and discounted by 3% per year. Persons are classified as having moderate comorbid conditions if they have an ulcer, rheumatologic disease, peripheral vascular disease, diabetes, paralysis, cerebrovascular disease, or a history of acute myocardial infarction; severe comorbid conditions if they have chronic obstructive pulmonary disease, congestive heart failure, moderate or severe liver disease, chronic renal failure, dementia, cirrhosis and chronic hepatitis, or AIDS; and no comorbid conditions if none of these conditions are present. In elderly persons without previous screening with no, moderate, or severe comorbid conditions, none of the screening strategies are cost-effective from age 87, 84, and 81 years onward, respectively (Figure 1). For each age, the efficient screening strategies are connected by an efficiency frontier. A solid line indicates that the ICER of a screening strategy is <$100 000 per QALY gained, implying that the strategy is considered cost-effective. A dashed line indicates that the ICER of a screening strategy exceeds $100 000 per QALY gained, implying that the strategy is not considered cost-effective. FIT = fecal immunochemical test; ICER = incremental cost-effectiveness ratio; QALY = quality-adjusted life-year.

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Appendix Figure 1.

Overview of the natural history module of Microsimulation Screening Analysis–Colon.

CRC = colorectal cancer.

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Appendix Figure 2.

Adenoma prevalence seen in selected autopsy studies versus prevalence simulated by Microsimulation Screening Analysis–Colon.

Observed results are shown only for the 2 largest studies on which the model has been calibrated. The model has additionally been calibrated to 8 other autopsy studies. Bars above and below the diamonds indicate 95% CIs.

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Appendix Figure 3.

CRC incidence seen before the introduction of screening versus incidence simulated by Microsimulation Screening Analysis–Colon.

Bars above and below the diamonds indicate 95% CIs. CRC = colorectal cancer; SEER = Surveillance, Epidemiology, and End Results.

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Appendix Figure 4.

Distal CRC incidence seen in the intervention group of the UK Flexible Sigmoidoscopy Screening Trial versus incidence simulated by Microsimulation Screening Analysis–Colon.

Bars above and below the diamonds indicate 95% CIs. CRC = colorectal cancer; UK = United Kingdom.

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Appendix Figure 5.

Integrating modules for 2 example patients.

CRC = colorectal cancer; LY = life-year.

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