Personalizing Colonoscopy Screening for Elderly Individuals Based on Screening History, Cancer Risk, and Comorbidity Status Could Increase Cost Effectiveness

Abstract

Background & Aims Colorectal cancer (CRC) screening decisions for elderly individuals are often made based primarily on age—other factors that affect the effectiveness and cost effectiveness of screening are often not considered. We investigated the relative importance of factors that could be used to identify those elderly individuals most likely to benefit from CRC screening and determined the maximum ages at which screening remains cost effective based on these factors. Methods We used a microsimulation model (Microsimulation Screening Analysis-Colon) that was calibrated to the incidence of CRC in the US and the prevalence of adenomas reported in autopsy studies to determine the appropriate age to stop colonoscopy screening in 19,200 cohorts of individuals defined by sex, race, screening history, background risk for CRC, and comorbidity status. We applied a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY) gained. Results When considering the factors included in the model, a less intensive screening history, a higher background risk for CRC, and fewer comorbidities were associated with cost-effective screening at older ages. Sex and race had only a small effect on the appropriate age to stop screening. For some individuals likely to be screened in current practice, screening resulted in a loss of QALYs, rather than a gain. For some individuals unlikely to be screened in current practice, screening was highly cost effective. Although screening some previously screened, low-risk individuals was not cost effective even when they were 66 y old, screening some healthy, high-risk individuals remained cost effective until they reached an age of 88 y. Conclusion The current approach to CRC screening in elderly individuals, in which decisions are often based primarily on age, is inefficient, resulting in underuse of screening for some and overuse of screening for others. CRC screening could be more effective and cost effective if individual factors for each patient are considered.

Cancer screening for older people: to screen or not to screen

“…van Hees' team also reported that fewer co-morbidities were associated with screening at older ages. 19 Lansdorp-Vogelaar et al 20 and Gross et al 21 whose studies are included in this review, also arrived at a similar conclusion.…”

“…A summary of the literature review of screening for colorectal cancer is shown in Table 1. [11][12][13][14][15][16][17][18][19][20][21][22]27 Hong Kong Med J ⎥ Volume 23 Number 5 ⎥ October 2017 ⎥ www.hkmj.org To quantify the effect of screening colonoscopy on prevention, early detection, and overdiagnosis in the last 10 years (As above) Colonoscopies had the advantages of prevention and early detection, with a low risk of over-diagnosis; 180 000 colorectal cancers are estimated to have been prevented (97% were prevented by screening colonoscopies done up to age 75 years); 1/121 screening colonoscopies were early detected up to age 80 years (89% by screening colonoscopies up to age 75 years); over-diagnosed in 1/1089 screening colonoscopies (58% arose from screening colonoscopies done on those age >70 years)…”

miR-517a is an independent prognostic marker and contributes to cell migration and invasion in human colorectal cancer

“…Carcinoembryonic antigen and cancer antigen 19-9 are widely used biomarkers for CRC diagnosis. Endoscopy and blood screening have been proved to effectively reduce the incidence and mortality of CRC (3). However, the prognosis of CRC patients remains poor, with a 50-59% 5-year survival rate (2).…”

Colorectal cancer screening is cost-effective in the elderly who have had less intense prior screening, high baseline risk of colorectal cancer and less comorbidities

“…van Hees et al ,1 tackled these questions for the elderly by modelling expected costs and benefits of colonoscopy for a multitude of groups characterised by specific combinations of risk factors including age, sex, race, personal characteristics, lifestyle factors, screening history and comorbidities. For each group they estimated: expected number of quality adjusted life years due to ill health from adverse events, colorectal cancer diagnoses and deaths; expected financial costs to those screened due to out-of-pocket expenses/lost income because of screening, treatment and comorbidities; and ratio of these two as a measure of cost-effectiveness.…”