Gastroenterology

Gastroenterology

Volume 149, Issue 6, November 2015, Pages 1425-1437
Gastroenterology

Original Research
Full Report: Clinical—Alimentary Tract
Personalizing Colonoscopy Screening for Elderly Individuals Based on Screening History, Cancer Risk, and Comorbidity Status Could Increase Cost Effectiveness

https://doi.org/10.1053/j.gastro.2015.07.042Get rights and content

Background & Aims

Colorectal cancer (CRC) screening decisions for elderly individuals are often made primarily on the basis of age, whereas other factors that influence the effectiveness and cost effectiveness of screening are often not considered. We investigated the relative importance of factors that could be used to identify elderly individuals most likely to benefit from CRC screening and determined the maximum ages at which screening remains cost effective based on these factors.

Methods

We used a microsimulation model (Microsimulation Screening Analysis-Colon) calibrated to the incidence of CRC in the United States and the prevalence of adenomas reported in autopsy studies to determine the appropriate age at which to stop colonoscopy screening in 19,200 cohorts (of 10 million individuals), defined by sex, race, screening history, background risk for CRC, and comorbidity status. We applied a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY) gained.

Results

Less intensive screening history, higher background risk for CRC, and fewer comorbidities were associated with cost-effective screening at older ages. Sex and race had only a small effect on the appropriate age to stop screening. For some individuals likely to be screened in current practice (for example, 74-year-old white women with moderate comorbidities, half the average background risk for CRC, and negative findings from a screening colonoscopy 10 years previously), screening resulted in a loss of QALYs, rather than a gain. For some individuals unlikely to be screened in current practice (for example, 81-year-old black men with no comorbidities, an average background risk for CRC, and no previous screening), screening was highly cost effective. Although screening some previously screened, low-risk individuals was not cost effective even when they were 66 years old, screening some healthy, high-risk individuals remained cost effective until they reached the age of 88 years old.

Conclusions

The current approach to CRC screening in elderly individuals, in which decisions are often based primarily on age, is inefficient, resulting in underuse of screening for some and overuse of screening for others. CRC screening could be more effective and cost effective if individual factors for each patient are considered.

Section snippets

Methods

To quantify the effectiveness and cost effectiveness of screening, we used Microsimulation Screening Analysis-Colon (MISCAN-Colon) (http://cisnet.cancer.gov/colorectal/profiles.html. Accessed October 1, 2015).

Effect of Age on the Effectiveness and Cost Effectiveness of Screening

The effectiveness of colonoscopy screening declined with increasing age. Although screening healthy, average risk, white women with a negative screening colonoscopy 10 years prior resulted in 27.8 QALYs gained per 1000 women 66 years of age, it resulted in a loss of QALYs rather than a gain in women 85 years of age and older (Figure 1A). On the other hand, the costs of screening increased with age, from $602,000 per 1000 women 66 years of age to $1,061,000 per 1000 women 90 years of age (

Discussion

In current practice, decisions on CRC screening for elderly individuals are often made primarily on the basis of age.6 Our study shows that this approach is inefficient, resulting in underuse of screening for some and overuse of screening for others. An 81-year-old black man with no comorbidities, an average background risk for CRC, and no prior screening, for example, might currently be denied screening, whereas our study shows that screening these individuals is highly cost effective (costs

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    Conflicts of interest The authors have no conflicts to disclose.

    Funding This study was supported by University of Michigan Medical School (contract number: 3001705234), Veterans Affairs Health Services Research and Development (contracts IIR 12-411 and CDA 09-213-2), and, in part, by National Cancer Institute as part of the Cancer Intervention and Surveillance Modeling Network (CISNET), which supported development of the Microsimulation Screening Analysis-Colon project (grant U01-CA152959). Sponsors had no role in the designs and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. None of the authors had any conflicts of interest to disclose.

    Author names in bold designate shared co-first authors.

    Authors share co-first authorship.

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