Cost-utility of colorectal cancer screening at 40 years old for average-risk patients

Nilofer S Azad; Ira L Leeds; Waruguru Wanjau; Eun J Shin; William V Padula

doi:10.1016/j.ypmed.2020.106003

Cost-utility of colorectal cancer screening at 40 years old for average-risk patients

Prev Med. 2020 Jan 27:133:106003. doi: 10.1016/j.ypmed.2020.106003. Online ahead of print.

Authors

Nilofer S Azad¹, Ira L Leeds², Waruguru Wanjau³, Eun J Shin⁴, William V Padula⁵

Affiliations

¹ Sidney Kimmel Comprehensive Cancer Center, Gastrointestinal Oncology Division, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: nazad2@jhmi.edu.
² Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: ileeds@jhmi.edu.
³ Department of Health Policy and Management, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. Electronic address: wwanjau1@jhmi.edu.
⁴ Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: eshin3@jhmi.edu.
⁵ Department of Health Policy and Management, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Department of Pharmaceutical & Health Economics, Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, USA. Electronic address: padula@healthpolicy.usc.edu.

Abstract

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.

Keywords: Colorectal cancer; Cost-benefit analysis; Decision trees; Economic evaluation; Endoscopy; Screening; Secondary prevention.

Grants and funding

T32 CA126607/CA/NCI NIH HHS/United States