Comparative Economic Evaluation of Data from the ACRIN National CT Colonography Trial with Three Cancer Intervention and Surveillance Modeling Network Microsimulations

Published Online:https://doi.org/10.1148/radiol.11102411

Our analysis of data from the American College of Radiology Imaging Network National CT Colonography Trial in three Cancer Intervention and Surveillance Modeling Network microsimulation models predicts CT colonography to be more costly and less effective than non-CT colonographic screening but net beneficial compared with no screening.

Purpose

To estimate the cost-effectiveness of computed tomographic (CT) colonography for colorectal cancer (CRC) screening in average-risk asymptomatic subjects in the United States aged 50 years.

Materials and Methods

Enrollees in the American College of Radiology Imaging Network National CT Colonography Trial provided informed consent, and approval was obtained from the institutional review board at each site. CT colonography performance estimates from the trial were incorporated into three Cancer Intervention and Surveillance Modeling Network CRC microsimulations. Simulated survival and lifetime costs for screening 50-year-old subjects in the United States with CT colonography every 5 or 10 years were compared with those for guideline-concordant screening with colonoscopy, flexible sigmoidoscopy plus either sensitive unrehydrated fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT), and no screening. Perfect and reduced screening adherence scenarios were considered. Incremental cost-effectiveness and net health benefits were estimated from the U.S. health care sector perspective, assuming a 3% discount rate.

Results

CT colonography at 5- and 10-year screening intervals was more costly and less effective than FOBT plus flexible sigmoidoscopy in all three models in both 100% and 50% adherence scenarios. Colonoscopy also was more costly and less effective than FOBT plus flexible sigmoidoscopy, except in the CRC-SPIN model assuming 100% adherence (incremental cost-effectiveness ratio: $26 300 per life-year gained). CT colonography at 5- and 10-year screening intervals and colonoscopy were net beneficial compared with no screening in all model scenarios. The 5-year screening interval was net beneficial over the 10-year interval except in the MISCAN model when assuming 100% adherence and willingness to pay $50 000 per life-year gained.

Conclusion

All three models predict CT colonography to be more costly and less effective than non-CT colonographic screening but net beneficial compared with no screening given model assumptions.

© RSNA, 2011

References

  • 1 Johnson CD, Chen MH, Toledano AY, et al.. Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Med 2008;359(12):1207–1217.
  • 2 Johnson CD, Toledano AY, Herman BA, et al.. Computerized tomographic colonography: performance evaluation in a retrospective multicenter setting. Gastroenterology 2003;125(3):688–695.
  • 3 Fletcher JG, Johnson CD, Welch TJ, et al.. Optimization of CT colonography technique: prospective trial in 180 patients. Radiology 2000;216(3):704–711.
  • 4 Yee J, Akerkar GA, Hung RK, Steinauer-Gebauer AM, Wall SD, McQuaid KR. Colorectal neoplasia: performance characteristics of CT colonography for detection in 300 patients. Radiology 2001;219(3):685–692.
  • 5 Johnson CD, Harmsen WS, Wilson LA, et al.. Prospective blinded evaluation of computed tomographic colonography for screen detection of colorectal polyps. Gastroenterology 2003;125(2):311–319.
  • 6 Cotton PB, Durkalski VL, Pineau BC, et al.. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA 2004;291(14):1713–1719.
  • 7 Rockey DC, Paulson E, Niedzwiecki D, et al.. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 2005;365(9456):305–311.
  • 8 Levin B, Lieberman DA, McFarland B, et al.. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008;58(3):130–160.
  • 9 Whitlock EP, Lin JS, Liles E, Beil TL, Fu R. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2008;149(9):638–658.
  • 10 Mandel JS, Bond JH, Church TR, et al.. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993;328(19):1365–1371.
  • 11 Hardcastle JD, Chamberlain JO, Robinson MH, et al.. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996;348(9040):1472–1477.
  • 12 Kronborg O, Fenger C, Olsen J, Jørgensen OD, Søndergaard O. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 1996;348(9040):1467–1471.
  • 13 Knudsen AB, McMahon PM, Gazelle GS. Use of modeling to evaluate the cost-effectiveness of cancer screening programs. J Clin Oncol 2007;25(2):203–208.
  • 14 Loeve F, Boer R, van Oortmarssen GJ, van Ballegooijen M, Habbema JD. The MISCAN-COLON simulation model for the evaluation of colorectal cancer screening. Comput Biomed Res 1999;32(1):13–33.
  • 15 Loeve F, Brown ML, Boer R, van Ballegooijen M, van Oortmarssen GJ, Habbema JD. Endoscopic colorectal cancer screening: a cost-saving analysis. J Natl Cancer Inst 2000;92(7):557–563.
  • 16 Rutter CM, Miglioretti DL, Savarino JE. Bayesian calibration of microsimulation models. J Am Stat Assoc 2009;104(488):1338–1350.
  • 17 Knudsen AB. Explaining secular trends in colorectal cancer incidence and mortality with an empirically-calibrated microsimulation model. Cambridge, Mass: Harvard University, 2005.
  • 18 Surveillance, Epidemiology and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat database: SEER 9 registries public use, based on November 2003 submission (1973–2001). Bethesda, Md: National Cancer Institute, 2004.
  • 19 Arias E. United States life tables, 2004. Natl Vital Stat Rep 2007;56(9):1–39.
  • 20 Welin S, Youker J, Spratt J. The rates and patterns of growth of 375 tumors of the large intestine and rectum observed serially by double contrast enema study (Malmoe technique). Am J Roentgenol Radium Ther Nucl Med 1963;90:673–687.
  • 21 Stryker SJ, Wolff BG, Culp CE, Libbe SD, Ilstrup DM, MacCarty RL. Natural history of untreated colonic polyps. Gastroenterology 1987;93(5):1009–1013.
  • 22 Hofstad B, Vatn MH, Andersen SN, et al.. Growth of colorectal polyps: redetection and evaluation of unresected polyps for a period of three years. Gut 1996;39(3):449–456.
  • 23 Arminski TC, McLean DW. Incidence and distribution of adenomatous polyps of the colon and rectum based on 1,000 autopsy examinations. Dis Colon Rectum 1964;7:249–261.
  • 24 Blatt LJ. Polyps of the colon and rectum. Dis Colon Rectum 1961;4(4):277–282.
  • 25 Clark JC, Collan Y, Eide TJ, et al.. Prevalence of polyps in an autopsy series from areas with varying incidence of large-bowel cancer. Int J Cancer 1985;36(2):179–186.
  • 26 Chapman I. Adenomatous polypi of large intestine: incidence and distribution. Ann Surg 1963;157:223–226.
  • 27 Bombi JA. Polyps of the colon in Barcelona, Spain: an autopsy study. Cancer 1988;61(7):1472–1476.
  • 28 Johannsen LG, Momsen O, Jacobsen NO. Polyps of the large intestine in Aarhus, Denmark: an autopsy study. Scand J Gastroenterol 1989;24(7):799–806.
  • 29 Jass JR, Young PJ, Robinson EM. Predictors of presence, multiplicity, size and dysplasia of colorectal adenomas: a necropsy study in New Zealand. Gut 1992;33(11):1508–1514.
  • 30 Rickert RR, Auerbach O, Garfinkel L, Hammond EC, Frasca JM. Adenomatous lesions of the large bowel: an autopsy survey. Cancer 1979;43(5):1847–1857.
  • 31 Vatn MH, Stalsberg H. The prevalence of polyps of the large intestine in Oslo: an autopsy study. Cancer 1982;49(4):819–825.
  • 32 Williams AR, Balasooriya BA, Day DW. Polyps and cancer of the large bowel: a necropsy study in Liverpool. Gut 1982;23(10):835–842.
  • 33 CISNET-Model Profiles. 2008. http://cisnet.cancer.gov/colorectal/profiles.html. Accessed February 4, 2009.
  • 34 Winawer SJ, Zauber AG, Fletcher RH, et al.. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology 2006;130(6):1872–1885.
  • 35 Zauber AG, Lansdorp-Vogelaar I, Wilschut J, et al.. Cost-effectiveness of DNA stool testing to screen for colorectal cancer. Centers for Medicare & Medicaid Services, 2007http://www.cms.hhs.gov/determinationprocess/downloads/id52TA.pdf. Accessed February 4, 2009.
  • 36 Pickhardt PJ. Incidence of significant complications at CT colonography: collective experience of the Working Group on Virtual Colonoscopy. [abstr]. Gastrointest Endosc 2006;63:AB202.
  • 37 Pickhardt PJ. Incidence of colonic perforation at CT colonography: review of existing data and implications for screening of asymptomatic adults. Radiology 2006;239(2):313–316.
  • 38 Limburg PJ, Fletcher JG. Making sense of CT colonography–related complication rates. Gastroenterology 2006;131(6):2023–2024, discussion 2024.
  • 39 Singh G, Mannalithara A, Mithal A, Gerson LB, Triadafilopoulos G. Perforation risk following colonoscopy: small but significant, and on the rise. [abstr]. Gastrointest Endosc 2007;65:AB320.
  • 40 Centers for Medicare & Medicaid Services. 2007 physician fee schedule. http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS1203203&intNumPerPage=10. Accessed February 4, 2009.
  • 41 Gatto NM, Frucht H, Sundararajan V, Jacobson JS, Grann VR, Neugut AI. Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Cancer Inst 2003;95(3):230–236.
  • 42 Iglehart JK. The new era of medical imaging: progress and pitfalls. N Engl J Med 2006;354(26):2822–2828.
  • 43 Sanaka MR, Shah N, Mullen KD, Ferguson DR, Thomas C, McCullough AJ. Afternoon colonoscopies have higher failure rates than morning colonoscopies. Am J Gastroenterol 2006;101(12):2726–2730.
  • 44 Yabroff KR, Lamont EB, Mariotto A, et al.. Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 2008;100(9):630–641.
  • 45 Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 1996;276(15):1253–1258.
  • 46 Mark DH. Visualizing cost-effectiveness analysis. JAMA 2002;287(18):2428–2429.
  • 47 Stinnett AA, Mullahy J. Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med Decis Making 1998;18(2 Suppl):S68–S80.
  • 48 Sonnenberg A, Delcò F, Bauerfeind P. Is virtual colonoscopy a cost-effective option to screen for colorectal cancer? Am J Gastroenterol 1999;94(8):2268–2274.
  • 49 Ladabaum U, Song K, Fendrick AM. Colorectal neoplasia screening with virtual colonoscopy: when, at what cost, and with what national impact? Clin Gastroenterol Hepatol 2004;2(7):554–563.
  • 50 Pickhardt PJ, Hassan C, Laghi A, Zullo A, Kim DH, Morini S. Cost-effectiveness of colorectal cancer screening with computed tomography colonography: the impact of not reporting diminutive lesions. Cancer 2007;109(11):2213–2221.
  • 51 Vijan S, Hwang I, Inadomi J, et al.. The cost-effectiveness of CT colonography in screening for colorectal neoplasia. Am J Gastroenterol 2007;102(2):380–390.
  • 52 Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137(2):96–104.
  • 53 Weinstein MC, O’Brien B, Hornberger J, et al.. Principles of good practice for decision analytic modeling in health-care evaluation: report of the ISPOR Task Force on Good Research Practices—Modeling Studies. Value Health 2003;6(1):9–17.
  • 54 Gluecker TM, Johnson CD, Wilson LA, et al.. Extracolonic findings at CT colonography: evaluation of prevalence and cost in a screening population. Gastroenterology 2003;124(4):911–916.
  • 55 Edwards JT, Wood CJ, Mendelson RM, Forbes GM. Extracolonic findings at virtual colonoscopy: implications for screening programs. Am J Gastroenterol 2001;96(10):3009–3012.
  • 56 Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med 2007;357(22):2277–2284.
  • 57 Zalis ME, Barish MA, Choi JR, et al.. CT colonography reporting and data system: a consensus proposal. Radiology 2005;236(1):3–9.
  • 58 Hassan C, Pickhardt PJ, Laghi A, et al.. Computed tomographic colonography to screen for colorectal cancer, extracolonic cancer, and aortic aneurysm: model simulation with cost-effectiveness analysis. Arch Intern Med 2008;168(7):696–705.
  • 59 Schrag D. The price tag on progress: chemotherapy for colorectal cancer. N Engl J Med 2004;351(4):317–319.
  • 60 Meropol NJ, Schulman KA. Cost of cancer care: issues and implications. J Clin Oncol 2007;25(2):180–186.
  • 61 Cullen J, Schwartz MD, Lawrence WF, Selby JV, Mandelblatt JS. Short-term impact of cancer prevention and screening activities on quality of life. J Clin Oncol 2004;22(5):943–952.
  • 62 Brodersen J, Thorsen H, Cockburn J. Validity of short-term consequences of cancer prevention and screening activities? J Clin Oncol 2005;23(1):244; author reply 244–245.
  • 63 Brodersen J, McKenna SP, Doward LC, Thorsen H. Measuring the psychosocial consequences of screening. Health Qual Life Outcomes 2007;5:3.
  • 64 Taupin D, Chambers SL, Corbett M, Shadbolt B. Colonoscopic screening for colorectal cancer improves quality of life measures: a population-based screening study. Health Qual Life Outcomes 2006;4:82.
  • 65 Subramanian S, Klosterman M, Amonkar MM, Hunt TL. Adherence with colorectal cancer screening guidelines: a review. Prev Med 2004;38(5):536–550.
  • 66 Ristvedt SL, McFarland EG, Weinstock LB, Thyssen EP. Patient preferences for CT colonography, conventional colonoscopy, and bowel preparation. Am J Gastroenterol 2003;98(3):578–585.
  • 67 Taylor SA, Halligan S, Saunders BP, Bassett P, Vance M, Bartram CI. Acceptance by patients of multidetector CT colonography compared with barium enema examinations, flexible sigmoidoscopy, and colonoscopy. AJR Am J Roentgenol 2003;181(4):913–921.
  • 68 Svensson MH, Svensson E, Lasson A, Hellström M. Patient acceptance of CT colonography and conventional colonoscopy: prospective comparative study in patients with or suspected of having colorectal disease. Radiology 2002;222(2):337–345.
  • 69 Akerkar GA, Yee J, Hung R, McQuaid K. Patient experience and preferences toward colon cancer screening: a comparison of virtual colonoscopy and conventional colonoscopy. Gastrointest Endosc 2001;54(3):310–315.
  • 70 Rajapaksa RC, Macari M, Bini EJ. Racial/ethnic differences in patient experiences with and preferences for computed tomography colonography and optical colonoscopy. Clin Gastroenterol Hepatol 2007;5(11):1306–1312.
  • 71 Shapiro JA, Seeff LC, Thompson TD, Nadel MR, Klabunde CN, Vernon SW. Colorectal cancer test use from the 2005 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev 2008;17(7):1623–1630.
  • 72 Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, van Ballegooijen M, Kuntz KM. Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med 2008;149(9):659–669.

Article History

Received December 14, 2010; revision requested February 1, 2011; revision received May 19; accepted May 24; final version accepted May 27.
Published online: Nov 2011
Published in print: Nov 2011