Marjolein J.E. Greuter, PhD; Clasine M. de Klerk, MD; Gerrit A. Meijer, MD, PhD; Evelien Dekker, MD, PhD; Veerle M.H. Coupé, PhD
Note: The authors completed the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) checklist (Supplement).
Financial Support: By Alpe d'HuZes, the Dutch Cancer Society (NKI 2013-6338), and a Stand Up To Cancer–Dutch Cancer Society International Translational Cancer Research Dream Team Grant (SU2C-AACR-DT1415). Stand Up To Cancer is a program of the Entertainment Industry Foundation, administered by the American Association for Cancer Research.
Disclosures: Dr. Meijer reports nonfinancial support from Exact Sciences and Sysmex outside the submitted work; has patents pending on several applications related to CRC-related biomarkers, including for screening purposes; and was involved in the development and implementation of the Dutch national CRC screening program and serves on the national program committee. Dr. Dekker reports grants and nonfinancial support from Fujifilm and Olympus and personal fees from Fujifilm and Tillotts outside the submitted work. Dr. Coupé reports grants from The Netherlands Organisation for Health Research and Development, Novartis, and CZ outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2891.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Not available. Statistical code: Readers who are interested in limited access to the computer code can contact Dr. Coupé (e-mail, email@example.com). Data set: Available from Dr. Coupé (e-mail, firstname.lastname@example.org).
Requests for Single Reprints: Marjolein J.E. Greuter, PhD, Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing, 1007 MB Amsterdam, the Netherlands; e-mail, email@example.com.
Current Author Addresses: Drs. Greuter and Coupé: Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing, 1007 MB Amsterdam, the Netherlands.
Drs. de Klerk and Dekker: Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
Dr. Meijer: Department of Pathology, Netherlands Cancer Institute, PO Box 90203, 1006 BE Amsterdam, the Netherlands.
Author Contributions: Conception and design: G.A. Meijer, E. Dekker, V.M.H. Coupé.
Analysis and interpretation of the data: M.J.E. Greuter, C.M. de Klerk, G.A. Meijer, E. Dekker, V.M.H. Coupé.
Drafting of the article: M.J.E. Greuter, C.M. de Klerk, V.M.H. Coupé.
Critical revision of the article for important intellectual content: M.J.E. Greuter, C.M. de Klerk, G.A. Meijer, E. Dekker, V.M.H. Coupé.
Final approval of the article: M.J.E. Greuter, C.M. de Klerk, G.A. Meijer, E. Dekker, V.M.H. Coupé.
Provision of study materials or patients: C.M. de Klerk, E. Dekker.
Statistical expertise: V.M.H. Coupé.
Obtaining of funding: G.A. Meijer.
Administrative, technical, or logistic support: C.M. de Klerk.
Collection and assembly of data: E. Dekker.
Population-based screening to prevent colorectal cancer (CRC) death is effective, but the effectiveness of postpolypectomy surveillance is unclear.
To evaluate the additional benefit in terms of cost-effectiveness of colonoscopy surveillance in a screening setting.
Microsimulation using the ASCCA (Adenoma and Serrated pathway to Colorectal CAncer) model.
Dutch CRC screening program and published literature.
Asymptomatic persons aged 55 to 75 years without a prior CRC diagnosis.
Health care payer.
Fecal immunochemical test (FIT) screening with colonoscopy surveillance performed according to the Dutch guideline was simulated. The comparator was no screening or surveillance. FIT screening without colonoscopy surveillance and the effect of extending surveillance intervals were also evaluated.
CRC burden, colonoscopy demand, life-years, and costs.
FIT screening without surveillance reduced CRC mortality by 50.4% compared with no screening or surveillance. Adding surveillance to FIT screening reduced mortality by an additional 1.7% to 52.1% but increased lifetime colonoscopy demand by 62% (from 335 to 543 colonoscopies per 1000 persons) at an additional cost of €68 000, for an increase of 0.9 life-year. Extending the surveillance intervals to 5 years reduced CRC mortality by 51.8% and increased colonoscopy demand by 42.7% compared with FIT screening without surveillance. In an incremental analysis, incremental cost-effectiveness ratios (ICERs) for screening plus surveillance exceeded the Dutch willingness-to-pay threshold of €36 602 per life-year gained.
When using a parameter set representing low colorectal lesion prevalence or when colonoscopy costs were halved or colorectal lesion incidence was doubled, screening plus surveillance became cost-effective compared with screening without surveillance.
Limited data on FIT performance and background CRC risk in the surveillance population.
Adding surveillance to FIT screening is not cost-effective based on the Dutch ICER threshold and substantially increases colonoscopy demand. Extending surveillance intervals to 5 years would decrease colonoscopy demand without substantial loss of effectiveness.
Alpe d'HuZes, Dutch Cancer Society, and Stand Up To Cancer.
Greuter MJ, de Klerk CM, Meijer GA, Dekker E, Coupé VM. Screening for Colorectal Cancer With Fecal Immunochemical Testing With and Without Postpolypectomy Surveillance Colonoscopy: A Cost-Effectiveness Analysis. Ann Intern Med. ;167:544–554. doi: 10.7326/M16-2891
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Published: Ann Intern Med. 2017;167(8):544-554.
Published at www.annals.org on 3 October 2017
Cancer Screening/Prevention, Colonoscopy/Sigmoidoscopy, Colorectal Cancer, Gastroenterology/Hepatology, Gastrointestinal Cancer.
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