Colorectal cancer screening for average-risk North Americans: an economic evaluation.
Colorectal cancer screening for average-risk North Americans: an economic evaluation.
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DOI：
10.1371/journal.pmed.1000370
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发表时间：
2010-11-23
期刊：
影响因子：
15.8
通讯作者：
Manns BJ
中科院分区：
文献类型：
--
作者：
Heitman SJ;Hilsden RJ;Au F;Dowden S;Manns BJ
对检测结直肠癌的不同筛查方法的经济分析表明，在美国或加拿大的环境中，与其他筛查方法相比，粪便免疫化学检测筛查的医疗保健成本较低。结直肠癌（CRC）符合世界卫生组织的大规模筛查标准，但大多数国家的筛查率很低。CRC筛查是资源密集型的，目前尚不清楚是否存在最佳策略。本研究的目的是在考虑所有相关筛查方式和当前CRC治疗费用的情况下，对平均风险的北美人群进行CRC筛查的经济评估。使用马尔可夫模型进行增量成本-效用分析，比较每年以愈创木为基础的粪便隐血检查（FOBT）或粪便免疫化学检查（FIT）、每3年一次的粪便DNA检查、每5年一次的乙状结肠镜检查或计算机断层扫描结肠镜检查和每10年一次的结肠镜检查。所有策略也与没有筛选的自然史组进行比较。鉴于以前已经测试了不同的FIT检测方法和收集方法，在报告检测腺瘤和结直肠癌的“低”、“中”和“高”测试性能特征的研究基础上，考虑了三种不同的FIT检测策略。腺瘤和结直肠癌患病率基于最近的系统回顾，而筛查依从性、测试表现和结直肠癌治疗费用基于公开数据。结果测量包括终身成本、癌症数量、癌症相关死亡、获得的质量调整生命年和增量成本效用比。进行敏感性和情景分析。年度FIT，假设中等范围的测试特征，与除FIT高外的所有策略（包括不筛查）相比更有效，成本更低。在10万名平均风险患者的一生中，癌症数量可以从4,857例减少到1,782例，CRC死亡人数可以从1,393例减少到457例，同时每人节省68加元。尽管当FIT的测试性能降低或管理CRC的成本降低（例如，对于不资助昂贵的生物化疗方案的司法管辖区）时，筛查FIT患者比不筛查的策略更昂贵，但使用FIT进行CRC筛查仍然具有经济吸引力。与不筛查和其他现有筛查策略相比，FIT筛查可降低CRC和CRC相关死亡的风险，并降低医疗保健成本。卫生政策决策者应考虑优先资助使用FIT的结直肠癌筛查。结直肠癌是北美男性和女性癌症死亡的第二大原因，请参见文章后面的编辑总结。结直肠癌筛查是降低发病率和死亡率的重要手段，符合世界卫生组织的大规模筛查标准。然而，多种CRC筛查方法是可用的。结肠镜检查对于识别腺瘤和癌具有很高的敏感性，并且在筛查检查过程中可以切除息肉，因此被视为结直肠癌筛查的金标准。然而，结肠镜检查与许多并发症有关，并且也存在准入障碍。另一种测试，愈创木粪潜血测试，已被证明可以降低结直肠癌的死亡率，但这种测试在识别结直肠癌肿瘤，特别是腺瘤方面的敏感性较低。与愈创木粪隐血检查和乙状结肠镜检查相比，粪便免疫化学检查也可检测粪便中的血液，具有改进的测试性能特征（高灵敏度和特异性），并有可能提高参与率。粪便DNA（一种粪便测试，基于检测癌组织脱落的DNA）是另一种筛查选择，计算机断层结肠镜检查（“虚拟”结肠镜检查）在检测晚期腺瘤和结直肠癌方面可能与结肠镜检查相媲美，但价格昂贵且需要完整的结肠准备。在缺乏可靠的比较证据来指导选择任何一种筛查方式的情况下，考虑到不同的检测性能特征以及与每种检测方式相关的成本和资源的重大差异，强有力的成本效益分析可能有助于卫生政策制定者决定是否提供筛查，如果提供，则有助于选择最适当和最具成本效益的筛查方式。在这项研究中，研究人员对北美所有相关结直肠癌筛查方式进行了全面的经济评估。研究人员使用增量成本-效益分析，复杂的建模技术和两个假设的患者队列（具有“平均风险”的个体，即没有结直肠癌家族史，年龄在50-64岁和65-75岁）来比较每年以愈创木为基础的粪便隐血检查或粪便免疫化学检查(研究人员考虑了三种不同的粪便免疫化学测试策略，这些测试和收集方法来自于报道“低”的研究。“中”和“高”测试性能特征)，粪便DNA每三年一次，乙状结肠软性镜检查或计算机断层结肠镜检查每5年一次，结肠镜检查每10年一次。研究人员还包括一个没有筛选的自然史组，作为对每种筛选方法的比较。对于他们模型的基线数据，研究人员使用了最近系统回顾中的腺瘤和结直肠患病率，并基于现有数据的筛查依从性、测试表现和结直肠治疗费用。研究人员发现，与所有策略（包括不筛查）相比，每年进行粪便免疫化学检测，具有中程检测特征，更有效，成本更低。使用这种筛查方式，在10万名平均风险患者的一生中，癌症数量可以从4,857例减少到1,393例，结肠直肠癌死亡人数可以从1,782例减少到457例，同时每人节省68加元。虽然在敏感性和情景分析中，当粪便免疫化学测试的测试性能降低或结肠直肠癌管理成本降低时，使用粪便免疫化学测试筛查患者比不筛查的策略更昂贵，但研究人员发现，使用粪便免疫化学测试筛查结肠直肠癌仍然是最具经济吸引力的筛查选择。这项基于模型的经济分析发现，粪便免疫化学测试比所有其他结肠直肠筛查策略更有效，成本更低，包括最常用的基于粪便的筛查测试、基于愈创木的粪便隐血测试和不筛查。此外，本研究表明，与所有其他筛查策略和不筛查相比，每年进行粪便免疫化学测试筛查（假设测试性能特征为中程）可降低结直肠癌和结直肠癌相关死亡的风险，并降低医疗保健成本。因此，卫生政策制定者应考虑优先资助粪便免疫化学检测作为结直肠癌的筛查方式。请通过本摘要的在线版本http://dx.doi.org/10.1371/journal.pmed.1000370访问这些网站。美国疾病控制中心（CDC）列出了结肠直肠癌筛查指南，CDC也提供了结肠直肠癌筛查的患者信息
An economic analysis of different screening methods for detection of colorectal cancers suggests that in US or Canadian settings, screening with fecal immunochemical testing results in lower health-care costs as compared with other screening approaches. Colorectal cancer (CRC) fulfills the World Health Organization criteria for mass screening, but screening uptake is low in most countries. CRC screening is resource intensive, and it is unclear if an optimal strategy exists. The objective of this study was to perform an economic evaluation of CRC screening in average risk North American individuals considering all relevant screening modalities and current CRC treatment costs. An incremental cost-utility analysis using a Markov model was performed comparing guaiac-based fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually, fecal DNA every 3 years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. All strategies were also compared to a no screening natural history arm. Given that different FIT assays and collection methods have been previously tested, three distinct FIT testing strategies were considered, on the basis of studies that have reported “low,” “mid,” and “high” test performance characteristics for detecting adenomas and CRC. Adenoma and CRC prevalence rates were based on a recent systematic review whereas screening adherence, test performance, and CRC treatment costs were based on publicly available data. The outcome measures included lifetime costs, number of cancers, cancer-related deaths, quality-adjusted life-years gained, and incremental cost-utility ratios. Sensitivity and scenario analyses were performed. Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high. Among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,782 and the number of CRC deaths from 1,393 to 457, while saving CAN$68 per person. Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive. CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies. Health policy decision makers should consider prioritizing funding for CRC screening using FIT. Please see later in the article for the Editors' Summary Colorectal (bowel) cancer is the second leading cause of cancer deaths for both men and women in North America. Colorectal cancer screening is an important means for reducing morbidity and mortality and fulfils the World Health Organization criteria for mass screening. However, a variety of CRC screening approaches are available. Colonoscopy is viewed as the gold standard of colorectal cancer screening as it has a high sensitivity for identifying adenomas and cancer and polyps can be removed during the screening examination. However, colonoscopy is associated with a number of complications and there are also barriers to access. Another type of test, the guaiac fecal occult blood test, has been shown to reduce mortality from colorectal cancer but this test has low sensitivity for identifying colorectal neoplasia, particularly adenomas. Fecal immunochemical tests, which also detect blood in the stool, have improved test performance characteristics (high sensitivity and specificity) and the potential to improve participation rates compared to guaiac fecal occult blood test and flexible sigmoidoscopy. Fecal DNA (a stool test, based on the detection of DNA shed by cancerous tissue) is another screening option, as is computed tomographic colonography (“virtual” colonoscopy), that might rival colonoscopy in detecting advanced adenomas and colorectal cancer but is expensive and requires a full colonic preparation. In the absence of firm comparative evidence to guide the selection of any one screening modality and given the varied test performance characteristics and the significant differences in costs and resources associated with each, a robust cost-effectiveness analysis might help health policy makers in deciding whether or not to offer screening and if so, in selecting the most appropriate and cost effective screening modality. In this study the researchers conducted a full economic evaluation of all relevant colorectal cancer screening modalities in North America. The researchers used an incremental cost-utility analysis, a sophisticated modeling technique, and two hypothetical patient cohorts (individuals with an “average risk,” i.e., no family history of colorectal cancer, aged 50–64 and 65–75) to compare guaiac-based fecal occult blood test or fecal immunochemical test annually (the researchers considered three distinct fecal immunochemical testing strategies on the basis of assays and collection methods taken from studies that have reported “low,” “mid,” and “high” test performance characteristics), fecal DNA every three years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. The researchers also included a no screening natural history arm as a comparison to each screening approach. For the baseline data of their model, the researchers used adenoma and colorectal prevalence rates from a recent systematic review and based screening adherence, test performance, and colorectal treatment costs on available data. The researchers found that annual fecal immunochemical testing with mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening). Using this screening modality, among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,393 and the number of deaths from colorectal cancer from 1,782 to 457, while saving CAN$68 per person. Although in the sensitivity and scenario analysis, screening patients using fecal immunochemical testing became more expensive than a strategy of no screening when the test performance of fecal immunochemical testing was reduced, or the cost of managing colorectal cancers was lowered, the researchers found that screening for colorectal cancer with fecal immunochemical testing remained the most economically attractive screening option. This model-based economic analysis found that fecal immunochemical testing is more effective and less costly than all other colorectal screening strategies, including the most commonly-used stool-based screening test, guaiac-based fecal occult blood testing, and no screening. Furthermore, this study suggests that annual screening with fecal immunochemical testing (assuming mid-range test performance characteristics) reduces the risk of colorectal cancer and colorectal cancer–related deaths, and lowers health care costs in comparison to all other screening strategies and to no screening. Therefore, health policy makers should consider prioritizing funding for fecal immunochemical testing as the screening modality for colorectal cancer. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000370. Cancer.org has information for patients on colorectal cancer The US Centers for Disease Control (CDC) list colorectal screening guidelines The CDC also provides patient information on colorectal cancer Screening
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影响因子：
39.2
作者：
Ahlquist DA;Sargent DJ;Loprinzi CL;Levin TR;Rex DK;Ahnen DJ;Knigge K;Lance MP;Burgart LJ;Hamilton SR;Allison JE;Lawson MJ;Devens ME;Harrington JJ;Hillman SL
通讯作者：
Hillman SL
影响因子：
2.9
作者：
Frew, E;Wolstenholme, JL;Whynes, DK
通讯作者：
Whynes, DK
影响因子：
39.2
作者：
Imperiale, TF;Wagner, DR;Ransohoff, DF
通讯作者：
Ransohoff, DF
影响因子：
19.7
作者：
Burling, D;Halligan, S;Taylor, SA
通讯作者：
Taylor, SA
影响因子：
10.3
作者：
HIXSON, LJ;FENNERTY, MB;GAREWAL, H
通讯作者：
GAREWAL, H