On the 2nd of October, the prestigious journal Annals of Internal Medicine published our paper on the costs-effectiveness of post-polypectomy surveillance for colorectal cancer. We found that adding colonoscopy surveillance to FIT-screening is not cost-effective based on the Dutch ICER threshold and uses considerable colonoscopy resources. Extending surveillance intervals to 5 years would decrease colonoscopy demand without substantial loss of effectiveness.
Background of our study
In 2014, the Netherlands have started with the stepwise implementation of a national colorectal cancer (CRC) screening programme. This programme consists of biennial faecal immunochemical test (FIT) screening in individuals aged 55-75 years. Individuals with a positive test outcome are referred to colonoscopy. Individuals in whom cancer is detected will be treated. If polyps, i.e. benign precursor lesions of CRC, are detected, these will be removed by means of polypectomy. Because these individuals have an increased risk of developing new polyps and cancer, they will enter a surveillance programme in which they are closely monitored. In this surveillance programme, individuals will undergo colonoscopy every three to five years, depending on the number, size and other characteristics of the polyps.
There is robust evidence that screening reduces CRC mortality. However, the effect of surveillance is less clear. Therefore, we aimed to evaluate the additional benefit in terms of cost-effectiveness of colonoscopy surveillance in a FIT-screening setting.
Our Adenoma and Serrated pathway to Colorectal CAncer (ASCCA) model was set up to simulate the Dutch screening programme with colonoscopy surveillance according to the Dutch guideline. The comparator was no screening and no surveillance. We also evaluated FIT-screening without colonoscopy surveillance and the effect of extending surveillance intervals.
FIT-screening without surveillance reduced CRC mortality with 50.4% compared to no screening and no surveillance. Adding surveillance to FIT-screening reduced mortality by an additional 1.7% to 52.1% but increased lifetime colonoscopy demand by 62% from 335 to 543 colonoscopies per 1,000 individuals. Adding surveillance to screening increased costs by €68,000 to achieve 0.9 LYG per 1,000 individuals. Extending surveillance intervals to five years decreased CRC mortality reduction to 51.8% whereas colonoscopy demand was decreased by 12%.
The current Dutch surveillance programme is probably too intensive.
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