Cost-effectiveness of screening for colorectal cancer in the general population
Cost-effectiveness of screening for colorectal cancer in the general population
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DOI：
10.1001/jama.284.15.1954
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发表时间：
2000-10-18
影响因子：
120.7
通讯作者：
Kuntz, KM
中科院分区：
文献类型：
--
作者：
Frazier, AL;Colditz, GA;Kuntz, KM
背景 近期一个专家小组建议，结直肠癌（CRC）平均风险人群从50岁开始使用几种策略中的一种进行CRC筛查。然而，不同CRC筛查策略的许多方面仍不确定。
目的 评估CRC筛查在平均风险个体中的后果、成本和成本效益。
设计 从社会角度使用马尔可夫模型进行成本效益分析。
研究对象 代表美国50岁CRC平均风险人群的假设研究对象。
环境 模拟美国的临床实践。
主要观察指标 比较22种不同CRC筛查策略（包括专家小组推荐的策略）的贴现终身成本、预期寿命和增量成本效益（CE）比。
结果 在一项基础案例分析中，假设初次筛查的依从性为60%，后续或监测结肠镜检查的依从性为80%。对于白人男性，最有效的策略是从50岁到85岁每年进行复水粪便潜血试验（FOBT）加乙状结肠镜检查（如果发现低风险或高风险息肉则进行结肠镜检查），每5年一次，与不筛查相比，该策略使癌症发病率降低60%，CRC死亡率降低80%，与每年进行未复水FOBT加每5年一次乙状结肠镜检查相比，每获得一个生命年的增量CE比为92900美元。在一项假设筛查和后续依从性为100%的基础案例分析中，筛查频率高于每10年一次则成本过高；每年进行复水FOBT加每5年一次乙状结肠镜检查与每10年一次相同策略相比，每获得一个生命年的增量CE比为489900美元。专家小组推荐的其他策略要么效果较差，要么每获得一个生命年的成本高于其他替代策略。每10年进行一次结肠镜检查不如每年进行FOBT加每5年一次乙状结肠镜检查的组合有效。然而，在55岁时进行一次结肠镜检查可实现每10年进行一次结肠镜检查所能降低的CRC死亡率的近一半。由于白人女性预期寿命增加以及黑人癌症死亡率增加，CRC筛查在这些人群中比在白人男性中更具成本效益。
结论 CRC筛查，即使在依从性不完善的情况下，也能显著降低CRC死亡率，其效果与其他癌症筛查程序相当。然而，依从率显著影响增量CE比。在这个CRC模型中，60%依从每5年一次的筛查计划大致相当于100%依从每10年一次的筛查计划。用于指导临床指南的数学模型需要考虑预期依从率。
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 FOBI plus sigmoidoscopy every 5 years. However, a single colonoscopy at age 55 years achieves nearly half of the reduction in CRC mortality obtainable with clolonoscopy 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 rests 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.