Comparison of Benefit-to-Burden Ratios for Stool-Based Colorectal Cancer Screening Tests in the U.S.: A Decision...

The U.S. Preventive Services Task Force recommends average-risk colorectal cancer screening beginning at age 45 years with the multitarget stool DNA test at 1-3-year intervals or annual fecal immunochemical tests. In this decision analytical model study, the validated Colorectal Cancer Adenoma Incidence and Mortality model incorporated updated aggregate test performance data to estimate the benefit-to-burden ratio of stool-based screening tests across recommended intervals and age ranges and identify the efficient strategies.

Screening strategies of multitarget stool DNA or fecal immunochemical tests at 1-3-year intervals over various age ranges were evaluated for average-risk individuals in the U.S. Performance inputs for an updated marker panel (next-generation multitarget stool DNA) and fecal immunochemical tests were obtained from a meta-analysis. The primary analysis was an efficient frontier generated for life-years gained (benefit) compared with no screening versus the number of lifetime colonoscopies (burden) for each screening strategy. Strategies are efficient if no other strategy provides more life-years gained with equivalent or fewer colonoscopies and are near efficient if they are within 3 days of life-years gained of the efficient frontier.

All screening strategies resulted in positive life-years gained versus no screening (178-352 life-years gained/1,000 individuals). Nine of the 11 efficient strategies started screening at age 45 years. Triennial next-generation multitarget stool DNA between ages 45 and 75 years was the only stool-screening strategy at U.S. Preventive Services Task Force-recommended ages and intervals that was efficient. Recommended strategies of annual fecal immunochemical tests and annual next-generation multitarget stool DNA between ages 45 and 75 years were near efficient.

Performance advantages associated with triennial next-generation multitarget stool DNA from ages 45 to 75 years provided the best benefit to burden of the age- and interval-recommended stool-based screening strategies.