Journal of the National Cancer Institute Advance Access originally published online on September 24, 2009
JNCI Journal of the National Cancer Institute 2009 101(20):1412-1422; doi:10.1093/jnci/djp319
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© The Author 2009. Published by Oxford University Press.
ARTICLES |
Effect of Rising Chemotherapy Costs on the Cost Savings of Colorectal Cancer Screening
Affiliations of authors: Department of Public Health (IL-V, MvB, JDFH) and Department of Gastroenterology and Hepatology and Department of Internal Medicine (EJK), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York (AGZ)
Correspondence to: Iris Lansdorp-Vogelaar, PhD, Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands (e-mail: i.vogelaar{at}erasmusmc.nl).
Background: Although colorectal cancer screening is cost-effective, it requires a considerable net investment by governments or insurance companies. If screening was cost saving, governments and insurance companies might be more inclined to invest in colorectal cancer screening programs. We examined whether colorectal cancer screening would become cost saving with the widespread use of the newer, more expensive chemotherapies.
Methods: We used the MISCAN-Colon microsimulation model to assess whether widespread use of new chemotherapies would affect the treatment savings of colorectal cancer screening in the general population. We considered three scenarios for chemotherapy use: the past, the present, and the near future. We assumed that survival improved and treatment costs for patients diagnosed with advanced stages of colorectal cancer increased over the scenarios. Screening strategies considered were annual guaiac fecal occult blood testing (FOBT), annual immunochemical FOBT, sigmoidoscopy every 5 years, colonoscopy every 10 years, and the combination of sigmoidoscopy every 5 years and annual guaiac FOBT. Analyses were conducted from the perspective of the health-care system for a cohort of 50-year-old individuals who were at average risk of colorectal cancer and were screened with 100% adherence from age 50 years to age 80 years and followed up until death.
Results: Compared with no screening, the treatment savings from preventing advanced colorectal cancer and colorectal cancer deaths by screening more than doubled with the widespread use of new chemotherapies. The lifetime average treatment savings were larger than the lifetime average screening costs for screening with Hemoccult II, immunochemical FOBT, sigmoidoscopy, and the combination of sigmoidoscopy and Hemoccult II (average savings vs costs per individual in the population: Hemoccult II, $1398 vs $859; immunochemical FOBT, $1756 vs $1565; sigmoidoscopy, $1706 vs $1575; sigmoidoscopy and Hemoccult II $1931 vs $1878). Colonoscopy did not become cost saving, but the total net costs of this strategy decreased from $1317 to $296 per individual in the population.
Conclusions: With the increase in chemotherapy costs for advanced colorectal cancer, most colorectal cancer screening strategies have become cost saving. As a consequence, screening is a desirable approach not only to reduce colorectal cancer incidence and mortality but also to control the costs of colorectal cancer treatment.
| CONTEXT AND CAVEATS Prior knowledge Colorectal cancer screening is cost-effective, but it requires a substantial net investment to implement. It is not known if colorectal cancer screening would become cost saving with the widespread use of the newer, more expensive chemotherapies for this disease. Study design The MISCAN-Colon microsimulation model was used to assess the treatment savings of colorectal cancer screening by annual guaiac fecal occult blood testing (FOBT), annual immunochemical FOBT, sigmoidoscopy every 5 years, colonoscopy every 10 years, and the combination of sigmoidoscopy every 5 years and annual guaiac FOBT in the general population in three chemotherapy treatment scenarios: the past, the present, and the near future. Contribution The treatment savings from screening were more than twice as high in the near-future scenario with the widespread use of expensive new chemotherapies than in the past scenario for all test strategies. This increase in savings makes screening with all strategies except colonoscopy cost saving. Implications Screening is a desirable approach not only to reduce colorectal cancer incidence and mortality but also to control the costs of colorectal cancer treatment. Limitations The increase in treatment costs from the present scenario to the near-future scenario may have been underestimated because therapies other than chemotherapy that increase treatment costs and survival were not included in this analysis. All patients with advanced disease, including elderly patients with comorbidities, were assumed to have received the new chemotherapies in the near-future scenario. From the Editors
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Manuscript received February 3, 2009; revised July 16, 2009; accepted August 13, 2009.
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J Natl Cancer Inst 2009 101: 1365.