Reinier G.S. Meester, PhD; Iris Lansdorp-Vogelaar, PhD; Sidney J. Winawer, MD, DSc; Ann G. Zauber, PhD; Amy B. Knudsen, PhD; Uri Ladabaum, MD, MS
Note: Dr. Meester had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
Acknowledgment: The authors thank Michał F. Kamiński, MD, PhD, and Magnus Løberg, MD, for their contributions to the model analysis (Dr. Kamiński shared data from the Polish CRC screening program on other-cause mortality in patients with adenomas) and validation (Dr. Løberg helped to interpret the postpolypectomy cancer mortality data from the Norwegian cancer registry). Neither received compensation for their contributions. The authors also acknowledge the late Prof. Wendy S. Atkin, OBE, for her important contributions to the field of CRC prevention. Two of her studies were used in this article for model validation.
Financial Support: The research reported in this article was supported by the National Cancer Institute of the National Institutes of Health under awards U01 CA 199335 (Drs. Meester, Lansdorp-Vogelaar, Zauber, and Knudsen) and P30 CA 008748 (Drs. Winawer and Zauber).
Disclosures: Dr. Ladabaum reports consultancies with Clinical Genomics, Covidien, Leerink, Motus GI, and Quorum and stock options in Lean Medical and Universal DX. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3633.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive 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. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol and data set: Available from Dr. Meester (e-mail, firstname.lastname@example.org). Statistical code: Not publicly available.
Corresponding Author: Reinier G.S. Meester, PhD, Department of Public Health, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; e-mail, email@example.com.
Current Author Addresses: Drs. Meester and Lansdorp-Vogelaar: Department of Public Health, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, the Netherlands.
Dr. Winawer: Memorial Sloan Kettering Cancer Center, 25 Sutton Place S, New York, NY 20022.
Dr. Zauber: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017.
Dr. Knudsen: Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac Street, Suite 1010, Boston, MA 02114.
Dr. Ladabaum: Stanford Medicine, 430 Broadway, Redwood City, CA 94063.
Author Contributions: Conception and design: R.G.S. Meester, I. Lansdorp-Vogelaar, U. Ladabaum.
Analysis and interpretation of the data: R.G.S. Meester, I. Lansdorp-Vogelaar, S.J. Winawer, A.B. Knudsen, U. Ladabaum.
Drafting of the article: R.G.S. Meester, U. Ladabaum.
Critical revision of the article for important intellectual content: I. Lansdorp-Vogelaar, S.J. Winawer, A.G. Zauber, A.B. Knudsen, U. Ladabaum.
Final approval of the article: R.G.S. Meester, I. Lansdorp-Vogelaar, S.J. Winawer, A.G. Zauber, A.B. Knudsen, U. Ladabaum.
Provision of study materials or patients: S.J. Winawer.
Statistical expertise: I. Lansdorp-Vogelaar, A.G. Zauber, U. Ladabaum.
Obtaining of funding: I. Lansdorp-Vogelaar, S.J. Winawer, A.G. Zauber, U. Ladabaum.
Collection and assembly of data: U. Ladabaum.
Surveillance of patients with colorectal adenomas has limited long-term evidence to support current practice.
To compare the lifetime benefits and costs of high- versus low-intensity surveillance.
U.S. cancer registry, cost data, and published literature.
U.S. patients aged 50, 60, or 70 years with low-risk adenomas (LRAs) (1 to 2 small adenomas) or high-risk adenomas (HRAs) (3 to 10 small adenomas or ≥1 large adenoma) removed after screening with colonoscopy or fecal immunochemical testing (FIT).
No further screening or surveillance, routine screening after 10 years, low-intensity surveillance (10 years after LRA removal and 5 years after HRA removal), and high-intensity surveillance (5 years after LRA removal and 3 years after HRA removal).
Colorectal cancer (CRC) incidence and incremental cost-effectiveness.
Without surveillance or screening, lifetime CRC incidence for patients aged 50 years was 10.9% after LRA removal and 17.2% after HRA removal at screening colonoscopy. Subsequent colonoscopic screening, low-intensity surveillance, or high-intensity surveillance decreased incidence by 39%, 46% to 48%, and 55% to 56%, respectively. Incidence of CRC and surveillance benefits were higher for adenomas detected at FIT screening and lower for older patients. High-intensity surveillance cost less than $30 000 per quality-adjusted life-year (QALY) gained compared with low-intensity surveillance.
High-intensity surveillance cost less than $100 000 per QALY gained in most alternative scenarios for adenoma recurrence, CRC incidence, longevity, quality of life, screening ages, surveillance ages, test performance, disutilities, and cost.
Few surveillance outcome data exist.
The model suggests that high-intensity surveillance as recommended in the United States provides modest but clinically relevant benefits over low-intensity surveillance at acceptable cost.
National Cancer Institute.
Meester RG, Lansdorp-Vogelaar I, Winawer SJ, et al. High-Intensity Versus Low-Intensity Surveillance for Patients With Colorectal Adenomas: A Cost-Effectiveness Analysis. Ann Intern Med. 2019;:. [Epub ahead of print 24 September 2019]. doi: 10.7326/M18-3633
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Published: Ann Intern Med. 2019.
Colonoscopy/Sigmoidoscopy, Colorectal Cancer, Gastroenterology/Hepatology, Gastrointestinal Cancer, Healthcare Delivery and Policy.
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