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A. Lindsay Frazier, MD, MSc; Graham A. Colditz, MD, DrPH; Charles S. Fuchs, MD, MPH; Karen M. Kuntz, ScD

JAMA. 2000;284:1954-1961.

Context  A recent expert panel recommended that persons at average risk of colorectal cancer (CRC) begin screening for CRC at age 50 years using 1 of several strategies. However, many aspects of different CRC screening strategies remain uncertain.

Objective  To assess the consequences, costs, and cost-effectiveness of CRC screening in average-risk individuals.

Design  Cost-effectiveness analysis from a societal perspective using a Markov model.

Subjects  Hypothetical subjects representative of the 50-year-old US population at average risk for CRC.

Setting  Simulated clinical practice in the United States.

Main Outcome Measures  Discounted lifetime costs, life expectancy, and incremental cost-effectiveness (CE) ratio, compared used 22 different CRC screening strategies, including those recommended by the expert panel.

Results  In 1 base-case analysis, compliance was assumed to be 60% with the initial screen and 80% with follow-up or surveillance colonoscopy. The most effective strategy for white men was annual rehydrated fecal occult blood testing (FOBT) plus sigmoidoscopy (followed by colonoscopy if either a low- or high-risk polyp was found) every 5 years from age 50 to 85 years, which resulted in a 60% reduction in cancer incidence and an 80% reduction in CRC mortality compared with no screening, and an incremental CE ratio of $92,900 per year of life gained compared with annual unrehydrated FOBT plus sigmoidoscopy every 5 years. In a base-case analysis in which compliance with screening and follow-up is assumed to be 100%, screening more often than every 10 years was prohibitively expensive; annual rehydrated FOBT plus sigmoidoscopy every 5 years had an incremental CE ratio of $489,900 per life-year gained compared with the same strategy every 10 years. Other strategies recommended by the expert panel were either less effective or cost more per year of life gained than the alternatives. Colonoscopy every 10 years was less effective than the combination of annual FOBT plus sigmoidoscopy every 5 years. However, a single colonoscopy at age 55 years achieves nearly half of the reduction in CRC mortality obtainable with colonoscopy every 10 years. Because of increased life expectancy among white women and increased cancer mortality among blacks, CRC screening was even more cost-effective in these groups than in white men.

Conclusions  Screening for CRC, even in the setting of imperfect compliance, significantly reduces CRC mortality at costs comparable to other cancer screening procedures. However, compliance rates significantly affect the incremental CE ratios. In this model of CRC, 60% compliance with an every 5-year schedule of screening was roughly equivalent to 100% compliance with an every 10-year schedule. Mathematical modeling used to inform clinical guidelines needs to take into account expected compliance rates.

Author Affiliations: Channing Laboratory, Department of Medicine, Brigham and Women's Hospital (Drs Frazier, Colditz, and Fuchs) and the Dana-Farber Cancer Institute (Drs Frazier and Fuchs), Harvard Medical School; and the Departments of Epidemiology (Dr Colditz) and Health Policy and Management (Dr Kuntz), Harvard School of Public Health, Boston, Mass.

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