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Cost-effectiveness in CRC screening may depend on patient participation
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Given equal participation rates, fecal immunochemical tests and colonoscopy are more effective and less expensive than multitarget stool DNA tests for average-risk colorectal cancer screening, according to the results of a simulation study.
However, the model showed that screening with a multitarget stool DNA (MT-sDNA) test — which is more sensitive but less specific than FIT, and has a higher cost per-test — may be cost-effective if substantially higher participation rates are achieved.
Uri Ladabaum
“A program using the MT-sDNA test every 3 years may provide clinical benefits that are comparable to those of annual FIT and colonoscopy every 10 years — but at a much higher cost,” Uri Ladabaum, MD, of the division of gastroenterology and hepatology at Stanford University School of Medicine, told Healio Gastroenterology. “If participation in screening with the MT-sDNA test is substantially higher than with the alternatives, however, its higher costs may be justifiable.”
Ladabaum and Ajitha Mannalithara, PhD, also from Stanford, used a Markov model of average-risk CRC screening in the U.S. to compare the potential effectiveness and cost-effectiveness of MT-sDNA vs. FIT or colonoscopy screening.
The model considered complex participation patterns over time based on real-world data reported from organized programs or opportunistic screening, which is more common in the U.S. It also considered the patient support costs of organized screening programs and the different costs of commercial insurer and Medicare payments.
The investigators identified 3 years as the base case MT-sDNA interval, which is the same interval approved by CMS.
In a scenario with optimal participation, FIT every year and colonoscopy every 10 years were less expensive and more effective at reducing CRC incidence and mortality than MT-sDNA every 3 years.
A scenario reflecting participation and patient support costs of successful organized FIT programs had 50% consistent participation, 27% intermittent participation and $153 per patient per FIT cycle (patient support costs were included in the cost of MT-sDNA tests). Based on this scenario, for MT-sDNA to be better than FIT (using a $100,000 per quality of life-year [QALY] gained threshold), it would need to achieve 68% consistent participation and 32% intermittent participation every 3 years, or it would need to cost 60% less than in the base case ($260 commercial, $197 Medicare).
Thus, compared with an organized annual FIT screening program, “MT-sDNA testing every 3 years could be cost effective if the MT-sDNA program could achieve consistent participation by approximately two-thirds of people, and intermittent participation by the rest,” the researchers wrote.
In a scenario reflecting opportunistic screening with annual FIT, with 15% consistent participation and 30% intermittent participation, MT-sDNA every 3 years would cost less than $100,000 per QALY gained if it achieved 1.7 times higher participation than FIT (>26% consistent, >51% intermittent participation).
“Compared with opportunistic use of yearly FIT ... MT-sDNA every 3 years could be cost effective at current MT-sDNA test costs if the patient support program that is included in its test cost could yield participation rates higher than 1.7-fold relative to the participation rates with FIT,” they wrote.
These estimates were confirmed by sensitivity analyses. FIT was preferred in 99.3% of iterations in the Monte Carlo simulations with optimal participation and a $100,000 per QALY gained threshold.
“Modeling studies like the one we performed can provide important information when definitive comparative trials with long-term follow-up and cancer outcomes are not available. We may never have such trials in this case,” Ladabaum added. – by Adam Leitenberger
Disclosures: Ladabaum reports he was a consultant to Exact Sciences in 2014, and currently serves as a consultant to Given Imaging and as a scientific advisor to Mauna Kea Technologies.
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