Gastroenterology

Gastroenterology

Volume 129, Issue 4, October 2005, Pages 1151-1162
Gastroenterology

Clinical–alimentary tract
Projected National Impact of Colorectal Cancer Screening on Clinical and Economic Outcomes and Health Services Demand

Presented in part at the 2004 annual meeting of the American Gastroenterological Association, New Orleans, Louisiana.
https://doi.org/10.1053/j.gastro.2005.07.059Get rights and content

Background & Aims: Colorectal cancer (CRC) screening is effective and cost-effective, but the potential national impact of widespread screening is uncertain. It is controversial whether screening colonoscopy can be offered widely and how emerging tests may impact health services demand. Our aim was to produce integrated, comprehensive estimates of the impact of widespread screening on national clinical and economic outcomes and health services demand. Methods: We used a Markov model and census data to estimate the national consequences of screening 75% of the US population with conventional and emerging strategies. Results: Screening decreased CRC incidence by 17%–54% to as few as 66,000 cases per year and CRC mortality by 28%–60% to as few as 23,000 deaths per year. With no screening, total annual national CRC-related expenditures were $8.4 billion. With screening, expenditures for CRC care decreased by $1.5–$4.4 billion but total expenditures increased to $9.2–$15.4 billion. Screening colonoscopy every 10 years required 8.1 million colonoscopies per year including surveillance, with other strategies requiring 17%–58% as many colonoscopies. With improved screening uptake, total colonoscopy demand increased in general, even assuming substantial use of virtual colonoscopy. Conclusions: Despite savings in CRC care, widespread screening is unlikely to be cost saving and may increase national expenditures by $0.8–$2.8 billion per year with conventional tests. The current national endoscopic capacity, as recently estimated, may be adequate to support widespread use of screening colonoscopy in the steady state. The impact of emerging tests on colonoscopy demand will depend on the extent to which they replace screening colonoscopy or increase screening uptake in the population.

Section snippets

Decision Analytic Model: Description, Calibration, and Validity

Our decision analytic Markov model (TreeAge Pro 2004; TreeAge Software Inc, Williamston, MA) and its inputs (Table 1) have been described in detail.3, 5, 6, 8 Readers interested in replicating the details of our model are referred to the technical appendix of the initial model publication,6 the updated model schematic,3 descriptions of model updates in the methods sections of 2 recent publications,3, 5 and the specific variable values in Table 1 in this report (all of which were used in

Life Expectancy and Cost-effectiveness

Persons undergoing screening gained an average of 0.045–0.063 discounted life-years, depending on the strategy (Table 2), translating into 37–51 undiscounted life-days gained per person. Because most persons never developed CRC under the natural history model, the gains in life expectancy were concentrated among the small percentage who benefited from screening, with average gains for these persons of 3.5–4.6 undiscounted life-years, depending on the strategy. No strategy was cost saving

Discussion

CRC screening is effective and cost-effective but underused. The potential national impact of widespread screening is uncertain, it is controversial whether screening colonoscopy can be offered widely, and the potential impact of emerging tests on health services demand is debated. To our knowledge, this is the first study to integrate estimates of national clinical impact, disease-related national expenditures, cost-effectiveness, and national demand for health services under multiple

References (81)

  • R.E. Schoen

    Surveillance after positive and negative colonoscopy examinationsissues, yields, and use

    Am J Gastroenterol

    (2003)
  • M.L. Brown et al.

    Current capacity for endoscopic colorectal cancer screening in the United Statesdata from the National Cancer Institute Survey of Colorectal Cancer Screening Practices

    Am J Med

    (2003)
  • C. Hur et al.

    An analysis of the potential impact of computed tomographic colonography (virtual colonoscopy) on colonoscopy demand

    Gastroenterology

    (2004)
  • G.C. Harewood et al.

    Colonoscopy practice patterns since introduction of Medicare coverage for average-risk screening

    Clin Gastroenterol Hepatol

    (2004)
  • S.J. Winawer et al.

    Colorectal cancer screeningclinical guidelines and rationale

    Gastroenterology

    (1997)
  • D.A. Ahlquist et al.

    Colorectal cancer screening by detection of altered human DNA in stoolfeasibility of a multitarget assay panel

    Gastroenterology

    (2000)
  • K.S. Tagore et al.

    Sensitivity and specificity of a stool DNA multitarget assay panel for the detection of advanced colorectal neoplasia

    Clin Colorectal Cancer

    (2003)
  • S. Syngal et al.

    The loss of stool DNA mutation abnormalities in colorectal neoplasia after treatment

    Gastroenterology

    (2003)
  • C.D. Johnson et al.

    Prospective blinded evaluation of computed tomographic colonography for screen detection of colorectal polyps

    Gastroenterology

    (2003)
  • C.D. Johnson et al.

    Computerized tomographic colonographyperformance evaluation in a retrospective multicenter setting

    Gastroenterology

    (2003)
  • B.C. Pineau et al.

    Virtual colonoscopy using oral contrast compared with colonoscopy for the detection of patients with colorectal polyps

    Gastroenterology

    (2003)
  • T.R. Levin et al.

    Complications of screening flexible sigmoidoscopy

    Gastroenterology

    (2002)
  • D.M. Eddy et al.

    Screening for colorectal cancer in a high-risk population. Results of a mathematical model

    Gastroenterology

    (1987)
  • M. Pignone et al.

    Screening for colorectal cancer in adults at average riska summary of the evidence for the U.S. Preventive Services Task Force

    Ann Intern Med

    (2002)
  • M. Pignone et al.

    Cost-effectiveness analyses of colorectal cancer screeninga systematic review for the U.S. Preventive Services Task Force

    Ann Intern Med

    (2002)
  • Colorectal cancer test use among persons aged > or = 50 years—United States, 2001

    MMWR Morb Mortal Wkly Rep

    (2003)
  • U. Ladabaum et al.

    Aspirin as an adjunct to screening for prevention of sporadic colorectal cancer. A cost-effectiveness analysis

    Ann Intern Med

    (2001)
  • US Census Bureau

    (2004)
  • Life tables

    Vital statistics of the United States

    (1998)
  • M.H. Vatn et al.

    The prevalence of polyps of the large intestine in Osloan autopsy study

    Cancer

    (1982)
  • A.R. Williams et al.

    Polyps and cancer of the large bowela necropsy study in Liverpool

    Gut

    (1982)
  • J.C. Clark et al.

    Prevalence of polyps in an autopsy series from areas with varying incidence of large-bowel cancer

    Int J Cancer

    (1985)
  • T.C. Arminski et al.

    Incidence and distribution of adenomatous polyps of the colon and rectum based on 1,000 autopsy examinations

    Dis Colon Rectum

    (1964)
  • R.R. Rickert et al.

    Adenomatous lesions of the large bowelan autopsy survey

    Cancer

    (1979)
  • L.A.G. Ries et al.

    SEER cancer statistics review, 1973–1994. NIH publication no. 97-2789

    (1997)
  • D.A. Lieberman et al.

    Use of colonoscopy to screen asymptomatic adults for colorectal cancer

    N Engl J Med

    (2000)
  • T.F. Imperiale et al.

    Results of screening colonoscopy among persons 40 to 49 years of age

    N Engl J Med

    (2002)
  • T.F. Imperiale et al.

    Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population

    N Engl J Med

    (2004)
  • P.J. Pickhardt et al.

    Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults

    N Engl J Med

    (2003)
  • Screening for colorectal cancer—United States, 1992-1993, and new guidelines

    MMWR Morb Mortal Wkly Rep

    (1996)
  • Cited by (135)

    • Smart capsule for targeted proximal colon microbiome sampling

      2022, Acta Biomaterialia
      Citation Excerpt :

      In addition to the high incidence and mortality rate, the direct and indirect costs of chronic colorectal disorders are a serious economical and healthcare concern. For instance, in the United States, approximately 20, 8.4, and 2.0 billion dollars are spent annually on the treatment of IBS, CRC, and diverticulitis, respectively [22–24]. These numbers are projected to grow rapidly in the coming years due to increasing consumption of processed food with high saturated fat and sugars, which has long been linked to increased gut microbial dysbiosis and chronic inflammation of the GI lumen, which are two of the leading risk factors for a wide range of pathological GI tract conditions [10,25–28].

    • Cost-Effectiveness of Current Colorectal Cancer Screening Tests

      2020, Gastrointestinal Endoscopy Clinics of North America
    • Cost-Effectiveness and National Effects of Initiating Colorectal Cancer Screening for Average-Risk Persons at Age 45 Years Instead of 50 Years

      2019, Gastroenterology
      Citation Excerpt :

      We first compared the clinical predictions of our validated decision analytic model of CRC screening18,19 to those of the model that informed the ACS recommendation.

    View all citing articles on Scopus

    Supported in part by National Institutes of Health award R01 CA101849-01A1.

    View full text