Cost-Effectiveness and National Effects of Initiating Colorectal Cancer Screening for Average-Risk Persons at Age 45 Years Instead of 50 Years
Cost-Effectiveness and National Effects of Initiating Colorectal Cancer Screening for Average-Risk Persons at Age 45 Years Instead of 50 Years
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DOI：
10.1053/j.gastro.2019.03.023
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发表时间：
2019-07-01
期刊：
影响因子：
29.4
通讯作者：
Schoen, Robert E.
中科院分区：
文献类型：
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作者：
Ladabaum, Uri;Mannalithara, Ajitha;Schoen, Robert E.
背景与目的：美国癌症协会建议在45岁而不是50岁开始结直肠癌(CRC)筛查。我们估计了采用这项建议的成本效益和国家影响。方法：我们在一个有效的马尔可夫模型中比较了筛选策略和可选的资源分配。我们基于按年龄和人口普查数据筛查参与率的国家预测。结果：在1000人中，在45岁而不是50岁开始进行结肠镜检查，避免了4例大肠癌和2例结直肠癌死亡，获得了14个质量调整寿命年(QALY)，每增加一个QALY成本为33,900美元，需要额外的结肠镜检查758次。这758个结肠镜检查可以用来筛查231名目前未筛查的55岁老人或342名目前未筛查的65岁老人，直至75岁。这些替代方案避免了13-14例CRC病例和6-7例CRC死亡，获得了27-28个折扣QALY，同时节省了163,700-445,800美元。提高粪便免疫化学检测异常结果后的结肠镜检查完成率带来了更大的好处和节省。在45岁而不是50岁开始粪便免疫化学检测的成本为7700美元/QALY。将目前的按年龄划分的筛查率提前5年可以在未来5年避免29,400例结直肠癌病例和11,100例结直肠癌死亡，但需要增加1070万次结肠镜检查，并增加104亿美元的成本。将50-75岁人群的筛查率提高到80%，将以三分之一的增量成本避免近3倍的CRC死亡。结论：在马尔可夫模型分析中，我们发现从45岁开始进行结直肠癌筛查可能具有成本效益。然而，通过提高未经筛查的老年人和高危人群的参与率，可以以较低的成本获得更大的好处。
BACKGROUND & AIMS: The American Cancer Society has recommended initiating colorectal cancer (CRC) screening at age 45 years instead of 50 years. We estimated the cost effectiveness and national effects of adopting this recommendation. METHODS: We compared screening strategies and alternative resource allocations in a validated Markov model. We based national projections on screening participation rates by age and census data. RESULTS: Screening colonoscopy initiation at age 45 years instead of 50 years in 1000 persons averted 4 CRCs and 2 CRC deaths, gained 14 quality-adjusted life-years (QALYs), cost $33,900/QALY gained, and required 758 additional colonoscopies. These 758 colonoscopies could instead be used to screen 231 currently unscreened 55-year-old persons or 342 currently unscreened 65-year-old persons, through age 75 years. These alternatives averted 13-14 CRC cases and 6-7 CRC deaths and gained 27-28 discounted QALYs while saving $163,700-$445,800. Improving colonoscopy completion rates after abnormal results from a fecal immunochemical test yielded greater benefits and savings. Initiation of fecal immunochemical testing at age 45 years instead of 50 years cost $7700/QALY gained. Shifting current age-specific screening rates to 5 years earlier could avert 29,400 CRC cases and 11,100 CRC deaths over the next 5 years but would require 10.7 million additional colonoscopies and cost an incremental 10.4 billion. Improving screening rates to 80% in persons who are 50-75 years old would avert nearly 3-fold more CRC deaths at one third the incremental cost. CONCLUSIONS: In a Markov model analysis, we found that starting CRC screening at age 45 years is likely to be cost effective. However, greater benefit, at lower cost, could be achieved by increasing participation rates for unscreened older and higher-risk persons.