Effectiveness, benefit harm and cost effectiveness of colorectal cancer screening in Austria

Abstract

Background: Clear evidence on the benefit-harm balance and cost effectiveness of population-based screening for colorectal cancer (CRC) is missing. We aim to systematically evaluate the long-term effectiveness, harms and cost effectiveness of different organized CRC screening strategies in Austria. Methods: A decision-analytic cohort simulation model for colorectal adenoma and cancer with a lifelong time horizon was developed, calibrated to the Austrian epidemiological setting and validated against observed data. We compared four strategies: 1) No Screening, 2) FIT: annual immunochemical fecal occult blood test age 40-75 years, 3) gFOBT: annual guaiac-based fecal occult blood test age 40-75 years, and 4) COL: 10-yearly colonoscopy age 50-70 years. Predicted outcomes included: benefits expressed as life-years gained [LYG], CRC-related deaths avoided and CRC cases avoided; harms as additional complications due to colonoscopy (physical harm) and positive test results (psychological harm); and lifetime costs. Tradeoffs were expressed as incremental harm-benefit ratios (IHBR, incremental positive test results per LYG) and incremental cost-effectiveness ratios [ICER]. The perspective of the Austrian public health care system was adopted. Comprehensive sensitivity analyses were performed to assess uncertainty. Results: The most effective strategies were FIT and COL. gFOBT was less effective and more costly than FIT. Moving from COL to FIT results in an incremental unintended psychological harm of 16 additional positive test results to gain one lifeyear. COL was cost saving compared to No Screening. Moving from COL to FIT has an ICER of 15,000 EUR per LYG. Conclusions: Organized CRC-screening with annual FIT or 10-yearly colonoscopy is most effective. The choice between these two options depends on the individual preferences and benefit-harm tradeoffs of screening candidates.

Cost-Effectiveness of Colorectal Cancer Genetic Testing

“…The screening methods considered in these studies were iFOBT (70%), colonoscopy (67%), gFOBT (42%), and sigmoidoscopy (30%), but they were not conclusive on which screening method is the best to adopt for population-based CRC screening programs [78]. While the study by Jahn et al [79] concluded that the most effective CRC screening method was iFOBT annually or colonoscopy every 10 years, the gFOBT was less effective and more expensive than the iFOBT. Colonoscopy was found to be cost-effective compared to no screening, and an ICER of 15,000 EUR per LY was obtained when colonoscopy was switched with the iFOBT [79].…”

“…While the study by Jahn et al [79] concluded that the most effective CRC screening method was iFOBT annually or colonoscopy every 10 years, the gFOBT was less effective and more expensive than the iFOBT. Colonoscopy was found to be cost-effective compared to no screening, and an ICER of 15,000 EUR per LY was obtained when colonoscopy was switched with the iFOBT [79]. A cost-benefit analysis study by Heavener et al [80] also showed that CRC screening gives great returns; however, health systems need to construct payment models to provide better incentives to health providers who implement CRC screening [81].…”

Colorectal cancer screening challenges in Saudi Arabia. A comprehensive review article

“…Furthermore, endoscopists performing the procedure should have fulfilled minimum training benchmarks as found in the US when screening patients ≥ 50 years of age [42]. Overall, a review study discussing the use of colonoscopy in the detection of CRC described 94.7% sensitivity across 49 studies encompassing 11,151 patients [43].…”

Colorectal cancer screening should begin at 45

“…The most informative empirical data emerge from the observation of rising incidence in multiple high resource nations but a different trend in Austria. Austria has instituted opportunistic screening at age 40, and as a result, colorectal cancer incidence is rising in individuals up until age 39 but declining in those 40 and over 11 …”