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High-Intensity Versus Low-Intensity Surveillance for Patients With Colorectal Adenomas: A Cost-Effectiveness Analysis
Reinier G S Meester1, Iris Lansdorp-Vogelaar2, Sidney J Winawer3
1Erasmus MC University Medical Center, Rotterdam, the Netherlands, and Stanford University, Stanford, California (R.G.M.).
Background:
Surveillance of patients with colorectal adenomas has limited long-term evidence to support current practice.
Objective:
To compare the lifetime benefits and costs of high- versus low-intensity surveillance.
Design:
Microsimulation model.
Data Sources:
U.S. cancer registry, cost data, and published literature.
Target Population:
U.S. patients aged 50, 60, or 70 years with low-risk adenomas (LRAs) (1 to 2 small adenomas) or high-risk adenomas (HRAs) (3 to 10 small adenomas or ≥1 large adenoma) removed after screening with colonoscopy or fecal immunochemical testing (FIT).
Time Horizon:
Lifetime.
Perspective:
Societal.
Intervention:
No further screening or surveillance, routine screening after 10 years, low-intensity surveillance (10 years after LRA removal and 5 years after HRA removal), and high-intensity surveillance (5 years after LRA removal and 3 years after HRA removal).
Outcome Measures:
Colorectal cancer (CRC) incidence and incremental cost-effectiveness.
Results Of Base-Case Analysis:
Without surveillance or screening, lifetime CRC incidence for patients aged 50 years was 10.9% after LRA removal and 17.2% after HRA removal at screening colonoscopy. Subsequent colonoscopic screening, low-intensity surveillance, or high-intensity surveillance decreased incidence by 39%, 46% to 48%, and 55% to 56%, respectively. Incidence of CRC and surveillance benefits were higher for adenomas detected at FIT screening and lower for older patients. High-intensity surveillance cost less than $30 000 per quality-adjusted life-year (QALY) gained compared with low-intensity surveillance.
Results Of Sensitivity Analysis:
High-intensity surveillance cost less than $100 000 per QALY gained in most alternative scenarios for adenoma recurrence, CRC incidence, longevity, quality of life, screening ages, surveillance ages, test performance, disutilities, and cost.
Limitation:
Few surveillance outcome data exist.
Conclusion:
The model suggests that high-intensity surveillance as recommended in the United States provides modest but clinically relevant benefits over low-intensity surveillance at acceptable cost.
Primary Funding Source:
National Cancer Institute.
