Risk-adapted approach feasible, cost-effective for population-based CRC screening
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A risk-adapted approach for population-based colorectal cancer screening was a viable and cost-effective option compared with existing colonoscopy and fecal immunochemical test strategies, according to new research in China.
“Current guidelines recommend employing a one-size-fits-all screening strategy (eg, colonoscopy every 10 years, fecal immunochemical test [FIT] every year or every other year) in the targeted population defined solely by age,” Hongda Chen, PhD, of the Medical Research Center at Peking Union Medical College Hospital in Beijing, and colleagues wrote in Clinical Gastroenterology and Hepatology. “This has drawbacks including unsatisfactory participation, low yield for neoplasia and high demand for endoscopy resources in population-based screening programs.”
They added, “Developing personalized risk-stratified screening strategies may help to overcome some of these drawbacks, such as the high demand for endoscopy resources.”
To compare the feasibility, screening yield and related costs of colonoscopy, FIT and a risk-adapted approach to CRC screening, Chen and colleagues randomly assigned 19,373 participants to one of three study arms in a 1:2:2 ratio: one-time colonoscopy (n = 3,883); annual FIT (n = 7,793); and annual risk-adapted screening (n = 7,697).
Participants underwent a risk assessment using the modified Asia-Pacific Colorectal Screening score, which considers CRC-related risk factors of age, sex, family history of CRC in first-degree relatives, BMI and cigarette smoking. Participants with a score of 4 or more were categorized as high risk and were referred to colonoscopy, while those with a score of less than 4 were considered low risk and referred to FIT.
Researchers conducted three screening rounds for all groups from May 2018 to May 2021. The detection rate of advanced colorectal neoplasms, including CRC and advanced precancerous lesions, served as the primary study outcome.
The mean participant age was 60.5 years, and 41.7% were men. Investigators found no significant differences among the groups regarding patient demographics, except that more participants in the risk-adapted groups had a family history of CRC.
According to the study, the percentage of participants who attended at least one screening was 42.3% for the colonoscopy group, 99.3% for the FIT group and 89.2% for the risk-adapted group.
An intention-to-treat analysis showed the detection rates for advanced neoplasm were 2.76% for colonoscopy, 2.17% for FIT and 2.35% for the risk-adapted screening group. The odds ratios were 1.27 for colonoscopy vs. FIT, 1.17 for colonoscopy vs. risk-adapted screening and 1.09 for risk-adapted screening vs. FIT after adjustment for age, sex and study center.
The number of colonoscopies needed to detect one advanced neoplasm was highest in the colonoscopy group (15.4), followed by the risk-adapted screening group (10.2) and FIT group (7.8).
From a government perspective, the cost for detecting one advanced neoplasm was $1,004 for colonoscopy, $844 for FIT and $970 for the risk-adapted screening.
Although researchers acknowledged study limitations, including lack of long-term assessment of CRC mortality and compliance concerns, they concluded that the risk-adapted screening was comparable to FIT for detecting advanced neoplasm vs. single colonoscopy and costs were comparable among all strategies.
“The risk-adapted approach would complement the well-established, one-size-fits-all strategies, especially for settings with limited colonoscopy resources,” the researchers wrote. “Further exploration of effective risk prediction scores is highly needed which may further improve the screening yield and efficiency of the risk-adapted screening strategy.”
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