粪便免疫化学检测联合或不联合息肉切除术后监测结肠镜检查用于结直肠癌筛查的成本效果分析。

Screening for Colorectal Cancer With Fecal Immunochemical Testing With and Without Postpolypectomy Surveillance Colonoscopy: A Cost-Effectiveness Analysis.

机构信息

From VU University Medical Center, Academic Medical Center, and Netherlands Cancer Institute, Amsterdam, the Netherlands.

出版信息

Ann Intern Med. 2017 Oct 17;167(8):544-554. doi: 10.7326/M16-2891. Epub 2017 Oct 3.

DOI:10.7326/M16-2891

PMID:28973514

Abstract

BACKGROUND

Population-based screening to prevent colorectal cancer (CRC) death is effective, but the effectiveness of postpolypectomy surveillance is unclear.

OBJECTIVE

To evaluate the additional benefit in terms of cost-effectiveness of colonoscopy surveillance in a screening setting.

DESIGN

Microsimulation using the ASCCA (Adenoma and Serrated pathway to Colorectal CAncer) model.

DATA SOURCES

Dutch CRC screening program and published literature.

TARGET POPULATION

Asymptomatic persons aged 55 to 75 years without a prior CRC diagnosis.

TIME HORIZON

Lifetime.

PERSPECTIVE

Health care payer.

INTERVENTION

Fecal immunochemical test (FIT) screening with colonoscopy surveillance performed according to the Dutch guideline was simulated. The comparator was no screening or surveillance. FIT screening without colonoscopy surveillance and the effect of extending surveillance intervals were also evaluated.

OUTCOME MEASURES

CRC burden, colonoscopy demand, life-years, and costs.

RESULTS OF BASE-CASE ANALYSIS: FIT screening without surveillance reduced CRC mortality by 50.4% compared with no screening or surveillance. Adding surveillance to FIT screening reduced mortality by an additional 1.7% to 52.1% but increased lifetime colonoscopy demand by 62% (from 335 to 543 colonoscopies per 1000 persons) at an additional cost of €68 000, for an increase of 0.9 life-year. Extending the surveillance intervals to 5 years reduced CRC mortality by 51.8% and increased colonoscopy demand by 42.7% compared with FIT screening without surveillance. In an incremental analysis, incremental cost-effectiveness ratios (ICERs) for screening plus surveillance exceeded the Dutch willingness-to-pay threshold of €36 602 per life-year gained.

RESULTS OF SENSITIVITY ANALYSIS

When using a parameter set representing low colorectal lesion prevalence or when colonoscopy costs were halved or colorectal lesion incidence was doubled, screening plus surveillance became cost-effective compared with screening without surveillance.

LIMITATION

Limited data on FIT performance and background CRC risk in the surveillance population.

CONCLUSION

Adding surveillance to FIT screening is not cost-effective based on the Dutch ICER threshold and substantially increases colonoscopy demand. Extending surveillance intervals to 5 years would decrease colonoscopy demand without substantial loss of effectiveness.

PRIMARY FUNDING SOURCE

Alpe d'HuZes, Dutch Cancer Society, and Stand Up To Cancer.

摘要

背景

基于人群的结直肠癌（CRC）筛查预防死亡是有效的，但息肉切除术后监测的效果尚不清楚。

目的

评估在筛查环境中结肠镜监测在成本效益方面的额外获益。

设计

使用 ASCCA（腺瘤和锯齿状途径至结直肠癌）模型进行微观模拟。

数据来源

荷兰 CRC 筛查计划和已发表的文献。

目标人群

无症状、年龄在 55 岁至 75 岁之间、无 CRC 既往诊断的人群。

时间范围

终生。

视角

医疗保健支付方。

干预措施

模拟进行粪便免疫化学测试（FIT）筛查，根据荷兰指南进行结肠镜监测。对照措施为不筛查或不监测。还评估了不进行 FIT 筛查和延长监测间隔的效果。

结果测量

CRC 负担、结肠镜需求、寿命和成本。

基础分析结果

与不筛查或不监测相比，FIT 筛查不进行监测可使 CRC 死亡率降低 50.4%。将监测添加到 FIT 筛查中可使死亡率进一步降低 1.7%至 52.1%，但会使终生结肠镜需求增加 62%（从每 1000 人 335 次增加到 543 次），增加的成本为 6.8 万欧元，增加 0.9 个寿命年。与不进行 FIT 筛查相比，将监测间隔延长至 5 年可使 CRC 死亡率降低 51.8%，并使结肠镜需求增加 42.7%。在增量分析中，与不进行筛查相比，加监测的增量成本效益比（ICER）超过了荷兰每增加 1 个寿命年 36602 欧元的支付意愿阈值。