Cost-Effectiveness of Multitarget Stool DNA Testing vs Colonoscopy or Fecal Immunochemical Testing for Colorectal Cancer Screening in Alaska Native People

Abstract

Objective: To estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults. Patients and Methods: A Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019. Results: With perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is costeffective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy. Conclusion: Each strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.

Cancer statistics forAmericanIndian andAlaskaNative individuals, 2022: Including increasing disparities in early onset colorectal cancer

“…H. pylori is also associated with hemorrhagic gastritis, which can cause false‐positive results in fecal occult blood tests (FOBT) 90,91 ; consequently, despite their potential utility in this rural population, FOBT is not recommended for CRC screening in Alaska Native individuals 92 . The Alaska Tribal Health System has prioritized access to endoscopic services 92 and, more recently, multitarget stool DNA testing (Cologuard; Exact Sciences Corporation), which is the most cost‐effective and effective screening method for this population 93 . As a result of these efforts, CRC screening rates in IHS facilities in Alaska 94 (59%) were higher than in any other PRCDA region in 2017 (Table 4), although earlier stage diagnosis and reduced mortality have yet to be achieved 85 …”

“…Access to colonoscopy and multitarget stool DNA tests 93,186 for CRC screening is of particular importance for Alaska Native individuals because of their high risk for the disease and for H. pylori‐associated hemorrhagic gastritis, 90,91 which can cause false‐positive fecal occult blood tests 92 . Alaska Native individuals face many challenges in obtaining colonoscopy services, including transportation barriers because many Alaska Native individuals live in areas that lack road networks.…”

“…Since the late 1990s, the Alaska Native Tribal Health Consortium has worked to improve access to endoscopy services by supporting colonoscopy field clinics in remote areas 92 . More recent efforts have focused on multitarget stool DNA testing, better known as Cologuard (Exact Sciences Corporation), which has proven to be a more cost‐effective option for expanding screening access for Alaska Native individuals, 93 with high levels of acceptability among providers 186 . These efforts by the Alaska Native Tribal Health Consortium have been crucial for Alaska’s achievement of the highest CRC screening prevalence (59%) of any IHS area (Table 4).…”

Epidemiology, Risk Factors, and Prevention of Colorectal Cancer-An English Version

“…However, the sensitivity of the FIT, which has been proven to be useful in the diagnosis of advanced adenomas, is limited to 5%-16% in the diagnosis of sessile serrated lesions, which account for 25%-30% of sporadic CRC precursors [40,41]. Therefore, there have been attempts (e.g., multitargeted fecal DNA test) to increase the sensitivity and specificity of stool tests by targeting tumor metabolites and genes rather than blood in the feces [42][43][44][45].…”

Development of a colorectal cancer screening intervention for Alaska Native people during a pandemic year

“…Previous research has shown increases in screening adherence among patients who use mt-sDNA, even among those who have never been screened, as well as an improvement in the quality of follow-up colonoscopies [ [17] , [18] , [19] ]. In previous research, our team demonstrated high sensitivity of mt-sDNA for cancer and large polyps among AN adults [ 16 ], interest in using mt-sDNA among AN patients and their healthcare providers [ 20 ], and that mt-sDNA is a cost-effective screening strategy in this population [ 21 ]. However, it is unknown if mt-sDNA is feasible in rural/remote AN communities, and whether use of mt-sDNA will actually increase AN CRC screening adherence.…”