Elsevier

European Journal of Radiology

Volume 82, Issue 11, November 2013, Pages e629-e636
European Journal of Radiology

Review
An international review of the main cost-effectiveness drivers of virtual colonography versus conventional colonoscopy for colorectal cancer screening: Is the tide changing due to adherence?

https://doi.org/10.1016/j.ejrad.2013.07.019Get rights and content

Abstract

Objectives

The majority of recent cost-effectiveness reviews concluded that computerised tomographic colonography (CTC) is not a cost-effective colorectal cancer (CRC) screening strategy yet. The objective of this review is to examine cost-effectiveness of CTC versus optical colonoscopy (COL) for CRC screening and identify the main drivers influencing cost-effectiveness due to the emergence of new research.

Methods

A systematic review was conducted for cost-effectiveness studies comparing CTC and COL as a screening tool and providing outcomes in life-years saved, published between January 2006 and November 2012.

Results

Nine studies were included in the review. There was considerable heterogeneity in modelling complexity and methodology. Different model assumptions and inputs had large effects on resulting cost-effectiveness of CTC and COL. CTC was found to be dominant or cost-effective in three studies, assuming the most favourable scenario. COL was found to be not cost effective in one study.

Conclusions

CTC has the potential to be a cost-effective CRC screening strategy when compared to COL. The most important assumptions that influenced the cost-effectiveness of CTC and COL were related to CTC threshold-based reporting of polyps, CTC cost, CTC sensitivity for large polyps, natural history of adenoma transition to cancer, AAA parameters and importantly, adherence. There is a strong need for a differential consideration of patient adherence and compliance to CTC and COL. Recent research shows that laxative-free CTC screening has the potential to become a good alternative screening method for CRC as it can improve patient uptake of screening.

Introduction

Data from the Global Burden of Disease Study 2010 ranks CRC on fourth place in terms of leading causes of years of life lost for the Western European Region, ranking 10th for high-income North America [1]. The disease burden of CRC will increase in the coming years due to an ageing population, with considerable impact on health care costs [2]. In the last few years, colorectal cancer (CRC) screening using computerised tomographic colonography (CTC), also referred to as virtual colonography, has attracted considerable attention, discussion on screening methods and clinical comparisons [3], and was the basis for numerous cost-effectiveness reviews [4], [5]. The majority of the reviews concluded that CTC is not a cost-effective screening strategy compared to other screening modalities yet. The objective of this review is to re-examine the cost-effectiveness of CTC as well as its major drivers, especially compared to conventional colonoscopy (COL) given the emergence of new research and data. The importance of the cost-effectiveness of CRC screening becomes all the more important, considering CRC is the third most common cancer worldwide [6].

Section snippets

Methods

For this review, studies had to compare CTC and COL as a primary screening tool, provide a related cost-effectiveness analysis for the two strategies and provide outcomes in life-years saved (LYS) in order to enable comparability. Studies published in peer reviewed journals between January 2006 and November 2012 were included in the review.

The search methodology was in line with PRISMA guidelines [7], including the use of the PICOS review system (see details in the Annex). The selection

Overall study features

Due to the strict application of quality criteria, a total of nine studies were included in the systematic review. A majority of 7 studies were based on US data, with 1 study based on Italian and 1 study based on British data. All studies focused on a screening population at average risk of CRC (for full information on study features, see supplementary Table I). The majority of seven studies used either Markov cohort modelling or state transition type Markov models as methodology. Two studies

Discussion

There was considerable heterogeneity in modelling complexity and methodology, but especially in the model assumptions and inputs mentioned above. These all had large effects on resulting cost-effectiveness of CTC and COL. We will discuss the main drivers that are likely to affect CTC cost-effectiveness and examine related assumptions in the light of new research data. The main cost-effectiveness drivers can be identified in the area of costs, natural history, diagnostic sensitivity and

Conclusion

There has been an established development in the last years, whereby CTC is considered cost-effective compared to no-screening [5], [23], which is also supported by this review. CTC has the potential to be a cost-effective CRC screening strategy when compared to COL. The main modelling assumptions that are likely to render CTC cost-effective are connected to natural history concepts, especially the rate in which large adenomas progress to CRC, a finding first suggested by [23] and confirmed by

Details on study selection

The following databases were searched: Medline, PubMed, Science Direct, Cochrane Library and the York Centre for Reviews and Dissemination databases. A comprehensive search strategy has been developed, using appropriate disease-related MeSH terms and economic filters. Search terms included the following: colonography, virtual colonoscopy, colonoscopy, cost and economics. The keywords were combined and adapted to search the above mentioned databases. For the discussion on the major drivers of

Role of the funding source

The research is supported by the German Federal Ministry of Education and Research (BMBF), project grant No. 01EX1013B, as part of the Centre of Excellence for Medical Technology.

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      Some models evaluated 5-yearly CTC and others evaluated 10-yearly and 15-yearly CTC. All studies [20,29,30–38] established that CTC is cost-effective compared with no screening. Contradicting results have emerged from two different studies which used ten-year simulation modelling to assess asymptomatic, average-risk population 50–74 years old; the first one was in UK [30] which found that CTC has the potential to bear a cost-effective choice for CRC screening in the UK, National health System (NHS) and may be cost saving compared with the existing program of biennial FOBT depending on the adherence rate and also yielded better health benefits in terms of QALYs and life-years.

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      Separate studies suggest CT colonography may be less cost-effective than other screening modalities, but more cost-effective than no screening [84]. However, cost analyses often inadequately account for extracolonic findings on CT colonography and may keep CT colonography from being cost-effective [84,85]. Modeling of low-income countries, including countries in Southeast Asia and Sub-Saharan Africa, suggest that CRC treatment should be prioritized and would be more cost-effective than screening [13].

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