Azad Nilofer S, Leeds Ira L, Wanjau Waruguru, Shin Eun J, Padula William V
Sidney Kimmel Comprehensive Cancer Center, Gastrointestinal Oncology Division, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Prev Med. 2020 Jan 27;133:106003. doi: 10.1016/j.ypmed.2020.106003.
The incidence of colorectal cancer (CRC) is increasing in patients under the age of 50. The purpose of this study was to assess the cost-utility of available screening modalities starting at 40 years in the general population compared to standard screening at 50 years old. A decision tree modeling average-risk of CRC in the United States population was constructed for the cost per quality-adjusted life year (QALY) of the five most common and effective CRC screening modalities in average-risk 40-year olds versus deferring screening until 50 years old (standard of care) under a limited societal perspective. All parameters were derived from existing literature. We evaluated the incremental cost-utility ratio of each comparator at a willingness-to-pay threshold of $50,000/QALY and included multivariable probabilistic sensitivity analysis. All screening modalities assessed were more cost-effective with increased QALYs than current standard care (no screening until 50). The most favorable intervention by net monetary benefit was flexible sigmoidoscopy ($3284 per person). Flexible sigmoidoscopy, FOBT, and FIT all dominated the current standard of care. Colonoscopy and FIT-DNA were both cost-effective (respectively, $4777 and $11,532 per QALY). The cost-effective favorability of flexible sigmoidoscopy diminished relative to colonoscopy with increasing willingness-to-pay. Regardless of screening modality, CRC screening at 40 years old is cost-effective with increased QALYs compared to current screening initiation at 50 years old, with flexible sigmoidoscopy most preferred. Consideration should be given for a general recommendation to start screening at age 40 for average risk individuals.
50岁以下人群的结直肠癌（CRC）发病率正在上升。本研究的目的是评估在普通人群中从40岁开始进行现有筛查方式的成本效益，与50岁开始的标准筛查进行比较。构建了一个决策树，模拟美国人群中患CRC的平均风险，以有限的社会视角计算40岁平均风险人群中五种最常见且有效的CRC筛查方式每获得一个质量调整生命年（QALY）的成本，同时与推迟筛查至50岁（标准治疗）进行对比。所有参数均来自现有文献。我们在支付意愿阈值为50,000美元/QALY的情况下评估了每个比较对象的增量成本效益比，并进行了多变量概率敏感性分析。所有评估的筛查方式与当前标准治疗（50岁前不筛查）相比，在增加QALY的同时更具成本效益。按净货币效益计算，最有利的干预措施是乙状结肠镜检查（每人3284美元）。乙状结肠镜检查、粪便潜血试验（FOBT）和粪便免疫化学试验（FIT）均优于当前标准治疗。结肠镜检查和FIT-DNA均具有成本效益（分别为每QALY 4777美元和11,532美元）。随着支付意愿的增加，乙状结肠镜检查相对于结肠镜检查的成本效益优势减弱。无论采用何种筛查方式，与目前50岁开始筛查相比，40岁开始进行CRC筛查在增加QALY的同时具有成本效益，其中乙状结肠镜检查最为首选。应考虑普遍建议平均风险个体从40岁开始进行筛查。
