Cost-effectiveness of colorectal cancer surveillance in ulcerative colitis

Key issues concerning colorectal cancer in inflammatory bowel disease include determination of the risk of colorectal cancer and assessment of interventions to increase survival. No randomized, controlled trials of colonoscopic surveillance compared to no surveillance exist; however, retrospective studies illustrate that surveillance is associated with improved survival, probably as a result of detection of cancer at earlier stages of disease. In the absence of prospective clinical trials of either prophylactic colectomy or surveillance colonoscopy to detect dysplasia, quantitative analysis has been utilized to estimate the impact of competing management strategies on costs and benefits. Published analyses show that while prophylactic colectomy will likely save the greatest number of life-years, quality of life is not optimal, and thus shared decision-making between provider and patient is recommended. Surveillance colonoscopy to detect early cancer and dysplasia appears to be cost-effective, although the risk of colorectal cancer must be substantial in order for this to hold true. It is estimated that the incidence of cancer in ulcerative colitis must exceed 27% over a 30-year period in order for surveillance colonoscopy every 2 years to be cost-effective. Determination of the optimal interval between surveillance procedures is also a contentious issue. Although annual surveillance colonoscopy may not be cost-effective, 3-4 year intervals yield cost-effectiveness ratios comparable to other medical practices deemed worthwhile by society, while 5-year interval produce an incremental cost-effectiveness similar to screening strategies in other diseases.