Gastroenterology

Gastroenterology

Volume 141, Issue 5, November 2011, Pages 1648-1655.e1
Gastroenterology

Original Research
Clinical—Alimentary Tract
Cost-effectiveness Analysis of a Quantitative Immunochemical Test for Colorectal Cancer Screening

https://doi.org/10.1053/j.gastro.2011.07.020Get rights and content

Background & Aims

Two European randomized trials (N = 30,000) compared guaiac fecal occult blood testing with quantitative fecal immunochemical testing (FIT) and showed better attendance rates and test characteristics for FIT. We aimed to identify the most cost-effective FIT cutoff level for referral to colonoscopy based on data from these trials and allowing for differences in screening ages.

Methods

We used the validated MIcrosimulation SCreening ANalysis (MISCAN)-Colon microsimulation model to estimate costs and effects of different screening strategies for FIT cutoff levels of 50, 75, 100, 150, and 200 ng/mL hemoglobin. For each cutoff level, screening strategies were assessed with various age ranges and screening intervals. We assumed sufficient colonoscopy capacity for all strategies.

Results

At all cost levels, FIT screening was most effective with the 50 ng/mL cutoff level. The incremental cost-effectiveness ratio of biennial screening between ages 55 and 75 years using FIT at 50 ng/mL, for example, was 3900 euro per life year gained. Annual screening had an incremental cost-effectiveness ratio of 14,900 euro per life year gained, in combination with a wider age range (between ages 45 and 80 years). In the sensitivity analysis, 50 ng/mL remained the preferred cutoff level.

Conclusions

FIT screening is more cost-effective at a cutoff level of 50 ng/mL than at higher cutoff levels. This supports the recommendation to use FIT at a cutoff level of 50 ng/mL, which is considerably lower than the values used in current practice.

Section snippets

MISCAN-Colon

The MISCAN-Colon microsimulation model and the data sources that inform the quantification of the model are described in detail in previous publications10, 11 and in a standardized model profile.12 In brief, the model simulates a large population of individuals from birth to death, first without screening and subsequently with screening. In every individual, one or more adenomas may arise and some of them may develop into cancer. Adenomas can progress from small (1–5 mm) to medium (6–9 mm) to

Cost-effectiveness Analysis

A FIT cutoff level of 50 ng/mL resulted in more life years gained at the same or lower costs than higher cutoff levels (Figure 1). Consequently, the efficient frontier consisted of FIT 50 strategies only. The higher the cutoff level used, the further the strategies were situated below the efficient frontier (see Supplementary Table 1 for detailed results on costs and effects for all cutoff levels).

The costs and life years gained of the efficient strategies under the assumption of 100%

Discussion

Our study shows that within the range analyzed (50–200 ng/mL), the optimal cutoff level for FIT screening with the quantitative OC sensor is 50 ng/mL. The cutoff level of 50 ng/mL has the highest sensitivity and lowest specificity. The decreased specificity of screening with FIT 50 was outweighed by the fact that it needed fewer rounds compared with screening with higher cutoff levels to be equally effective.

A one-way sensitivity analysis to evaluate the impact of uncertain parameters showed

Acknowledgments

This paper was reviewed by Metamorfose Vertalingen.

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    Conflicts of interest The authors disclose no conflicts.

    Funding Supported by The Netherlands Organization for Health Research and Development of the Dutch Ministry of Health (ZonMW 62200022 and 63300022).

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