Optimizing Colonoscopy Capacity to Maximize Colorectal Cancer Outcomes

Guidelines support endoscopic and stool-based testing for average-risk colorectal cancer (CRC) screening, but colonoscopy capacity is limited. With an aim to screen all eligible individuals, we identified scenarios that maximized the benefits of colonoscopy utilization for both screening and follow-up of noninvasive screening.

Annual current screening modality distribution in the United States was modeled. Clinical outcomes and costs were compared between the current distribution and alternative scenarios that substituted initial colonoscopy screening with stool-based tests, such that the total number of follow-up colonoscopies after positive stool-based tests plus screening colonoscopies would maintain the full colonoscopy capacity.

To screen all eligible individuals in the United States (58.3 million) and utilize full colonoscopy capacity (15 million/y), stool-based tests must increase 2.4-fold, follow-up colonoscopies after positive stool-based tests must increase from the current 9% of capacity to 22% (1.4-3.3 million), and screening colonoscopies must decrease from the current 33% of capacity to 20% (4.9-3.0 million). In this optimal screening modality distribution scenario, the number of detected CRC cases would increase by 84% vs current distribution (185,710 vs 100,860), 49% more CRC cases would be prevented (83,299 vs 55,897), total CRC costs (ie, CRC screening, treatment, and savings from CRC prevented) would decrease from $117.8 billion to $110.6 billion, and colonoscopy revenue would increase from $13.4 billion to $13.9 billion due to a higher proportion of therapeutic procedures with polypectomy.

Reallocating indications for colonoscopies by substituting some screening colonoscopies with follow-up colonoscopies-while performing at full capacity-along with a shift in initial CRC screening modalities to more stool-based testing, could increase health benefits, maximize colonoscopy efficiency and revenue, and reduce expenditures.