Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
J Natl Cancer Inst. 2011 Dec 7;103(23):1741-51. doi: 10.1093/jnci/djr385. Epub 2011 Nov 9.
Fecal occult blood testing (FOBT) can be adapted to a limited colonoscopy capacity by narrowing the age range or extending the screening interval, by using a more specific test or hemoglobin cutoff level for referral to colonoscopy, and by restricting surveillance colonoscopy. Which of these options is most clinically effective and cost-effective has yet to be established.
We used the validated MISCAN-Colon microsimulation model to estimate the number of colonoscopies, costs, and health effects of different screening strategies using guaiac FOBT or fecal immunochemical test (FIT) at various hemoglobin cutoff levels between 50 and 200 ng hemoglobin per mL, different surveillance strategies, and various age ranges. We optimized the allocation of a limited number of colonoscopies on the basis of incremental cost-effectiveness.
When colonoscopy capacity was unlimited, the optimal screening strategy was to administer an annual FIT with a 50 ng/mL hemoglobin cutoff level in individuals aged 45-80 years and to offer colonoscopy surveillance to all individuals with adenomas. When colonoscopy capacity was decreasing, the optimal screening adaptation was to first increase the FIT hemoglobin cutoff value to 200 ng hemoglobin per mL and narrow the age range to 50-75 years, to restrict colonoscopy surveillance, and finally to further decrease the number of screening rounds. FIT screening was always more cost-effective compared with guaiac FOBT. Doubling colonoscopy capacity increased the benefits of FIT screening up to 100%.
FIT should be used at higher hemoglobin cutoff levels when colonoscopy capacity is limited compared with unlimited and is more effective in terms of health outcomes and cost compared with guaiac FOBT at all colonoscopy capacity levels. Increasing the colonoscopy capacity substantially increases the health benefits of FIT screening.
粪便潜血检测（FOBT）可通过缩小年龄范围或延长筛查间隔、使用更特异的检测方法或血红蛋白临界值进行结肠镜检查转诊、限制监测结肠镜检查来适应有限的结肠镜检查能力。然而，哪种方案在临床和经济上最有效尚未确定。
我们使用经过验证的 MISCAN-Colon 微观模拟模型，通过不同的血红蛋白临界值（50-200ng/ml 血红蛋白）、不同的监测策略以及不同的年龄范围，对不同的筛查策略（使用愈创木脂 FOBT 或粪便免疫化学检测（FIT））进行了结肠镜检查数量、成本和健康效果的估计。我们基于增量成本效益优化了有限结肠镜检查数量的分配。
当结肠镜检查能力不受限时，最佳的筛查策略是在 45-80 岁人群中进行每年一次的 FIT 检测，且血红蛋白临界值为 50ng/ml，并对所有腺瘤患者进行结肠镜监测。当结肠镜检查能力下降时，最佳的筛查适应策略是首先将 FIT 血红蛋白临界值提高到 200ng/ml 血红蛋白，将年龄范围缩小到 50-75 岁，限制结肠镜监测，最后进一步减少筛查轮次。与愈创木脂 FOBT 相比，FIT 筛查始终更具成本效益。将结肠镜检查能力增加一倍可使 FIT 筛查的获益增加 100%。
当结肠镜检查能力有限时，与无限相比，FIT 应该在更高的血红蛋白临界值下使用，并且在所有结肠镜检查能力水平下，在健康结果和成本方面，FIT 比愈创木脂 FOBT 更有效。大幅增加结肠镜检查能力可显著增加 FIT 筛查的健康获益。
