Cost-effectiveness of CRC screening after age 75 varies by sex, comorbidities, history
Key takeaways:
- Older age, male sex, higher comorbidity status and recent screenings were associated with reduced cost-effectiveness.
- Optimal stopping ages ranged from 76 to 86 years for colonoscopy and 76 to 88 years for FIT.
Cost-effectiveness and optimal stopping ages for colorectal cancer screening after age 75 years appear to be associated with an individual’s age, sex, comorbidity status and screening history, according to results of an economic evaluation.
“The burden and benefits of CRC screening depend on the individual’s overall life expectancy and CRC risk,” Matthias Harlass, MS, of the department of public health at Erasmus University Medical Center, and colleagues wrote in JAMA Network Open. “Previous studies investigated the optimal CRC stopping ages in a limited number of scenarios or alternative settings and did not validate their findings against community-based data in the U.S.
“Therefore, little evidence is available to guide decision-making regarding the optimal stopping age and screening modality moving forward for more complex combinations of patient characteristics.”
From a cost-effectiveness lens, Harlass and colleagues conducted an economic evaluation to identify the optimal ages to stop CRC screening by sex, comorbidity and screening history. They first validated the Microsimulation Screening Analysis-Colon model against community-based data from two Optimizing Colorectal Cancer Screening Precision and Outcomes in Community-Based Populations (PRECISE) subcohorts and simulated benefits, harms and costs of screening among individuals aged 76 to 90 years.
Studied endpoints included estimated lifetime clinical outcomes, incremental costs and quality-adjusted life-years gained (QALYG) from one additional CRC screening.
The first PRECISE subcohort included 25,974 adults (58% women; 54.7% aged 76-80 years, 66.2% white) with a negative colonoscopy 10 years prior to the index date, while the second included 118,269 adults (56.7% women; 90.5% aged 76-80 years; 63.8% white) with a negative fecal immunochemical test 1 year prior to the index date. Cumulative 8-year incidences of CRC were 1.29% and 1.21%, respectively.
According to results, older age, male sex, higher comorbidity and recent screenings were associated with reduced benefit and cost-effectiveness of additional screenings. The model estimated the highest number of life-years gained as well as CRC deaths averted at age 76 years, with a “sharp reduction” in screening benefit at older ages.
Using a reference cohort, one additional colonoscopy cost $38,226 per QALYG for women at age 76 years with no comorbidities and a negative colonoscopy 10 years prior to index. Costs increased to $1,689,945 per QALYG for women at age 90 years with similar comorbidity and colonoscopy characteristics and to $51,604 per QALYG for men with these characteristics at age 76 years. For women with severe comorbidities and negative colonoscopy results, the costs rose to $108,480 per QALYG at age 76 years.
Costs decreased to $16,870 per QALYG among women without comorbidities and a negative colonoscopy 30 years prior to index age.
Researchers noted FIT was associated with lower estimated incremental cost-effectiveness vs. colonoscopy for all screening histories “except screening-naive cohorts.”
Optimal stopping ages ranged from younger than 76 to 86 years for colonoscopy and younger than 76 to 88 years for FIT.
“Findings from this economic evaluation using community-based data on CRC risk suggest that the clinical outcomes, cost-effectiveness and optimal stopping age for CRC screening are associated with sex, comorbidity, prior screening and future screening modality,” Harlass and colleagues wrote. “Therefore, personalizing CRC screening based on these factors after age 75 years may play a role in the improvement of screening efficiency and reduction of potential harms.”
Collapse
Read more about