Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
Maple Health Group, New York, NY, USA.
J Med Econ. 2023 Jan-Dec;26(1):1219-1226. doi: 10.1080/13696998.2023.2260681. Epub 2023 Oct 6.
The United States Preventive Services Taskforce (USPSTF) recently recommended lowering the age for average-risk colorectal cancer (CRC) screening from 50 to 45 years. While initiating screening at age 45 versus 50 provides a greater opportunity for CRC early detection and prevention, the full profile of benefits, risks, and cost-effectiveness of expanding the screen-eligible population requires further evaluation.
The costs and clinical outcomes for screening at age 45 for triennial multi-target stool DNA [mt-sDNA], and other non-invasive stool-based modalities (annual fecal immunochemical test [FIT] and annual fecal-occult blood test [FOBT]), were estimated using the validated CRC-AIM microsimulation model over a lifetime horizon. Test sensitivity and specificity inputs were based on 2021 USPSTF modeling analyses; adherence rates were based on published real-world data and the costs of the screening test, follow-up colonoscopies, complications, and CRC care were included. Outcomes are reported from the perspective of a United States payer as clinical, life-years gained (LYG), and incremental cost-effectiveness ratio (ICER); stool-based and follow-up colonoscopy adherence ranges were explored in one-way, probabilistic and threshold analyses.
When compared to initiation of CRC screening at age 45 versus 50, all modalities reduced both the incidence of and mortality from CRC and increased LYG. Initiating CRC screening at age 45 was cost-effective with an ICER of $59,816 and $35,857 per quality-adjusted life year (QALY) for mt-sDNA versus FIT and FOBT, respectively. In the threshold analyses, at equivalent rates to stool-based screening, mt-sDNA was always cost-effective at a willingness-to-pay threshold of $100,000 per QALY versus FIT and FOBT.
Initiating average-risk CRC screening at age 45 instead of age 50 increases the estimated clinical benefit by reducing disease burden while remaining cost-effective. Among stool-based screening modalities, mt-sDNA provides the most clinical benefit in a Commercial and Medicare population.
美国预防服务工作组（USPSTF）最近建议将平均风险结直肠癌（CRC）筛查的年龄从 50 岁降低到 45 岁。虽然在 45 岁而不是 50 岁开始筛查为 CRC 的早期发现和预防提供了更大的机会，但扩大筛查合格人群的全部益处、风险和成本效益需要进一步评估。
使用经过验证的 CRC-AIM 微观模拟模型，在终身范围内估计了 45 岁时进行三联粪便多靶点 DNA（mt-sDNA）筛查和其他非侵入性粪便检测（每年粪便免疫化学测试[FIT]和每年粪便潜血测试[FOBT]）的成本和临床结果。检测敏感性和特异性输入基于 2021 年 USPSTF 建模分析；依从率基于已发表的真实世界数据和筛查检测、随访结肠镜检查、并发症和 CRC 治疗的成本。结果从美国支付者的角度报告为临床、生命年增加（LYG）和增量成本效益比（ICER）；对基于粪便的检测和随访结肠镜检查的依从率进行了单因素、概率和阈值分析。
与在 45 岁而非 50 岁开始 CRC 筛查相比，所有检测方法均降低了 CRC 的发病率和死亡率，并增加了 LYG。在 45 岁时开始 CRC 筛查，对于 mt-sDNA 与 FIT 和 FOBT 相比，ICER 分别为 59816 美元和 35857 美元/质量调整生命年（QALY），具有成本效益。在阈值分析中，以与基于粪便的筛查相同的速率，mt-sDNA 在 100000 美元/QALY 的支付意愿阈值下始终比 FIT 和 FOBT 具有成本效益。
在商业和医疗保险人群中，与在 50 岁时开始平均风险 CRC 筛查相比，在 45 岁时开始筛查可通过降低疾病负担来提高估计的临床获益，同时保持成本效益。在基于粪便的筛查方法中，mt-sDNA 在商业和医疗保险人群中提供了最大的临床获益。
