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17 October 2000 | Volume 133 Issue 8 | Pages 573-584
Background: Fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy are used to screen patients for colorectal cancer.
Objective: To compare the cost-effectiveness of fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy.
Design: The cost-effectiveness of the three screening strategies was compared by using computer models of a Markov process. In the model, a hypothetical population of 100 000 persons 50 years of age undergoes annual fecal occult blood testing, sigmoidoscopy every 5 years, or colonoscopy every 10 years. Positive results on fecal occult blood testing or adenomatous polyps found during sigmoidoscopy are worked up by using colonoscopy. After polypectomy, colonoscopy is repeated every 3 years until no polyps are found.
Data Sources: Transition rates were estimated from U.S. vital statistics and cancer statistics and from published data on the sensitivity, specificity, and efficacy of various screening techniques. Costs of screening and cancer care were estimated from Medicare reimbursement data.
Target Population: Persons 50 years of age in the general population.
Time Horizon: The study population was followed annually until death.
Perspective: Third-party payer.
Outcome Measure: Incremental cost-effectiveness ratio.
Results of Base-Case Analysis: Compared with colonoscopy, annual screening with fecal occult blood testing costs less but saves fewer life-years. A screening strategy based on flexible sigmoidoscopy every 5 or 10 years is less cost-effective than the other two screening methods.
Results of Sensitivity Analysis: Screening with fecal occult blood testing is more sensitive to changes in compliance rates, and it becomes easily dominated by colonoscopy under most conditions assuming less than perfect compliance. Other assumptions about the sensitivity and specificity of fecal occult blood testing, screening frequency, efficacy of colonoscopy in preventing cancer, and polyp incidence have a lesser influence on the differences in cost-effectiveness between colonoscopy and fecal occult blood testing.
Conclusions: Colonoscopy represents a cost-effective means of screening for colorectal cancer because it reduces mortality at relatively low incremental costs. Low compliance rates render colonoscopy every 10 years the most cost-effective primary screening strategy for colorectal cancer.
Author and Article Information
From the Department of Veterans Affairs Medical Center and the University of New Mexico, Albuquerque, New Mexico.
Grant Support: By the Centers for Disease Control and Prevention (Dr. Sonnenberg), the Swiss Foundation for Grants in Medicine and Biology (Dr. Delcò), and an American College of Gastroenterology Faculty Development Award (Dr. Inadomi).
Requests for Single Reprints: Amnon Sonnenberg, MD, MSc, Department of Veterans Affairs Medical Center 111F, 1501 San Pedro Drive SE, Albuquerque, NM 87108.
Current Author Addresses: Dr. Sonnenberg; Department of Veterans Affairs Medical Center 111F, 1501 San Pedro Drive SE, Albuquerque, NM 87108.
Dr. Delcò: Gastroenterologie, Kantonsspital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
Dr. Inadomi: Department of Veterans Affairs Medical Center 111D, 2215 Fuller Road, Ann Arbor, MI 48105.
Author Contributions: Conception and design: A. Sonnenberg, F. Delcò, J.M. Inadomi.
Analysis and interpretation of the data: A. Sonnenberg, F. Delcò, J.M. Inadomi.
Drafting of the article: A. Sonnenberg, F. Delcò.
Critical revision of the article for important intellectual content: A. Sonnenberg, F. Delcò, J.M. Inadomi.
Final approval of the article: A. Sonnenberg, F. Delcò, J.M. Inadomi.
Provision of study materials or patients: A. Sonnenberg, F. Delcò.
Statistical expertise: A. Sonnenberg, J.M. Inadomi.
Obtaining of funding: A. Sonnenberg.
Administrative, technical, or logistic support: A. Sonnenberg.
Collection and assembly of data: A. Sonnenberg, F. Delcò. ARTICLE
Cost-Effectiveness of Colonoscopy in Screening for Colorectal Cancer
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