Excerpt

Despite recent declines in both incidence and mortality, colorectal cancer (CRC) is the second most common cause of cancer death in the United States. CRC screening has been shown to reduce CRC mortality by 15–33% in randomized controlled trials with Hemoccult II fecal occult blood testing (FOBT). Novel CRC screening technologies, such as computed tomography (CT) colonography have been developed but need to be evaluated in terms of their comparability of performance (sensitivity and specificity) in detecting adenomatous polyps and CRC, acceptability to patients, and test-related complications and costs. Accordingly, we conducted a cost-effectiveness analysis of CT colonography and other currently recommended CRC screening strategies.

Contents

• ABBREVIATIONS
• EXECUTIVE SUMMARY
• BACKGROUND
• LITERATURE REVIEW FOR CT COLONOGRAPHY TEST CHARACTERISTICS
  • Department of Defense Study (Used for base case analysis)
  • National CT Colonography Trial (Used for base case analysis)
  • Department of Defense Study Primary 2D versus Primary 3D CT Colonography (Used for sensitivity analysis)
  • Johnson 2D versus 3D CT Colonography Study (Used for sensitivity analysis)
• COST-EFFECTIVENESS ANALYSIS
  • Overview
  • Microsimulation Modeling
  • Study Population
  • Comparison Screening Strategies
  • CT Colonography Strategies
  • CRC Screening Test Characteristics
  • CT Colonography Screening Test Characteristics
  • CRC Screening Test Characteristics for non-CT colonography
  • Costs
  • Analysis
• RESULTS
  • Projected Undiscounted Outcomes with Screening
  • Cost-Effectiveness Analysis from Payer Perspective
  • Threshold Analyses
  • Sensitivity Analyses
• DISCUSSION
  • Summary of Results
  • Cost-effectiveness of Currently Recommended Test Strategies
  • Evaluation of New Screening Tests in Relationship to Current Recommendations
  • Cumulative radiation exposure
  • Extracolonic findings
  • Consistency of Results from Three Microsimulation Models
  • Other Cost-effectiveness Analyses
  • Limitations of Modeling Assumptions
  • Limitations of Cost Estimates
• CONCLUSIONS
• REFERENCES
• APPENDICES
  • Appendix 1 Model descriptions
  • Appendix 2 Comparison of the MISCAN, SimCRC and CRC-SPIN models on natural history outcomes at age 65
  • Appendix 3 Additional outcomes of the analyses: Average Cost-Effectiveness Analysis Ratios (ACER)
  • Appendix 4 Results for the secondary threshold analyses
  • Appendix 5 Results for a cohort of 50-year-olds
  • Appendix 6 Derivation of costs per screening test by point of service for frequency weights, CPT codes and resulting cost estimates, as reported in the CISNET report to CMS on DNA stool testing

Acknowledgements: We acknowledge Martin Brown, Ph.D. and Robin Yabroff, Ph.D. of the National Cancer Institute (NCI) for their assistance with obtaining cancer treatment costs using SEER-Medicare data; Joan Warren, Ph.D. and Carrie Klabunde, Ph.D. of NCI for sharing their preliminary analysis of SEER-Medicare data on colonoscopy-related complications; John Allen, M.D. of Minnesota Gastroenterology, Minneapolis, MN and Joel Brill, M.D. of Predictive Health of Phoenix, AZ for their assistance in deriving coding for screening and complications; Beth McFarland, M.D. and Pam Kassing, M.S. of the American College of Radiology for assistance in coding and costs for CT colonography, William Lawrence, M.D. and Kim Wittenberg, M.A of AHRQ for contextual and administrative assistance, respectively, and William Larson, of the Centers for Medicare and Medicaid Services (CMS) for providing CMS cost data.

This report is based on research conducted by the CISNET under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (HHSP233200800231A [MSKCC], HHSP233200800323A [ErasmusMC], HHSP233200800270A [University of Minnesota], and HHSP233200800234A [Group Health Cooperative]). The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decision-makers; patients and clinicians, health system leaders, and policymakers, make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators has any affiliations or financial involvement related to the material presented in this report.