Age-related cancer detection rate and costs for one cancer detected in one screening by immunochemical fecal occult blood test

Performance of the Fecal Immunochemical Test in Detecting Advanced Colorectal Neoplasms and Colorectal Cancers in People Aged 40-49 Years: A Systematic Review and Meta-Analysis

BACKGROUND

The incidence of early-onset colorectal cancer (CRC) is increasing. Many guidelines recommend initiating screening at 45 years. This study investigated the detection rate of advanced colorectal neoplasm (ACRN) by using fecal immunochemical tests (FITs) in individuals aged 40-49 years.

METHODS

PubMed, Embase, and Cochrane Library databases were searched from inception to May 2022. The primary outcomes were the detection rates and positive predictive values of FITs for ACRN and CRC in people aged 40-49 (younger age group) and ≥50 years (average risk group).

RESULTS

Ten studies with 664,159 FITs were included. The FIT positivity rate was 4.9% and 7.3% for the younger age and average risk groups, respectively. Younger individuals with positive FIT results had significantly higher risks of ACRN (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.79-3.73) or CRC (OR 2.86, 95% CI 1.59-5.13) than did individuals in the average-risk group, regardless of FIT results. Individuals aged 45-49 years with positive FIT results had a similar risk of ACRN (OR 0.80, 95% CI 0.49-1.29) to that of people aged 50-59 years with positive FIT results, although significant heterogeneity was observed. The positive predictive values of the FIT were 10-28.1% for ACRN and 2.7-6.8% for CRC in the younger age group.

CONCLUSION

The detection rate of ACRN and CRC based on FITs in individuals aged 40-49 years is acceptable, and the yield of ACRN might be similar between individuals aged 45-49 and 50-59 years. Further prospective cohort and cost-effective analysis are warranted.

Long-term endoscopic surveillance for Barrett's esophagus in Japan: Multicenter prospective cohort study

OBJECTS

Although a recent study showed the cancer incidence of Barrett's esophagus (BE) to be 1.2%/year in 251 patient-years in Japan, the long-term outcomes remain unclear. The present study estimated the cancer risk of BE in Japan using our original prospective multicenter cohort.

METHODS

A total of 98 patients with BE of maximum length of ≥2 cm were enrolled during the period of 2010-2012 and received at least one follow-up endoscopy over 5 years thereafter. Cancer incidence rates with 95% confidence interval for occurrence of esophageal adenocarcinoma (EAC) were calculated as the number of events divided by patient-years of follow-up and were expressed as %/year.

RESULTS

Overall, the median endoscopic follow-up period was 59.9 (first and third quartiles, 48.5-60.8) months, constituting a total of 427 patient-years of observation. Since two EAC cases developed, the cancer incidence was 0.47% (0.01%-1.81%)/year. The cancer incidence was 0.39% (-0.16% to 2.44%) in 232 patient-years and 0.31% (-0.13% to 1.95%)/year in 318 patient-years for 55 cases with specialized intestinal metaplasia and 70 with BE ≥3 cm (maximum), respectively. At the end of follow-up, 12 of 92 patients (13.0%) died, but none died from EAC.

CONCLUSION

This is the largest prospective follow-up study with endoscopy to investigate the incidence of EAC in unequivocal BE with the maximum length of ≥2 cm in Japan. Although a further large-scale study will be required to validate our results, the cancer risk of BE in Japan would be lower than previously reported (0.47% vs 1.2%/year).

Empirical evidence of the continuing improvement in cost efficiency of an endoscopic surveillance programme for gastric cancer in Singapore from 2004 to 2010

Background

Endoscopic surveillance has been proven effective in prolonging the survival of gastric cancer (GC) patients. However, there is limited evidence on the cost efficiency of delivering this intervention, especially on a national level in spite of cost efficiency being a major determinant of the actual cost-effectiveness of a cancer prevention programme. The Singapore Gastric Cancer Epidemiology Clinical and Genetic Programme (GCEP) is a demonstration project offering scheduled endoscopy to the Chinese population aged 50 years or older in Singapore. By assessing the cost efficiency of the GCEP, this study aimed to provide empirical evidence on the cost structure and mechanisms underlying cost generation in conducting GC surveillance, thus informing resource allocation and programme budgeting for the Singapore government.

Methods

From a societal perspective, we reported on the direct cost (resource consumption) of conducting endoscopic surveillance through the GCEP network. We retrospectively collected individual-level data of 216 subjects recruited at the National University Hospital, Singapore from 01/04/2004 to 31/10/2010. The Overall Cost, Clinical Cost, GCEP Cost and Personal Cost incurred in serving one subject was computed and discounted as 2004 US dollar (US$) per capita for every year. The Generalized Estimation Equation (GEE) was used to model the data.

Results

All cost indices continuously declined over the 6.5-year costing period. For the total sample, Overall Cost, Clinical Cost, GCEP Cost and Personal Cost declined by 42.3%, 54.1%, 30% and 25.7% respectively. This downward trend existed for age and gender subgroups and the high risk group only with cost reductions varying between 3.5% and 58.4%. The GEE models confirmed statistical significance of the downward trend and of its association with risk profile, where the moderate risk group had cost indices at most 77% of the high risk group.

Conclusions

Our study offered empirical evidence of improved cost efficiency of a surveillance programme for GC in the early phase of programme implementation. Mechanisms such as economies of scale and self-learning were found to be involved in the cost reduction. Our findings highlighted the importance of assessing the cost efficiency and offered valuable insights for future programme budgeting and policy making.

Economic impact of screening for bladder cancer using bladder tumor markers: A decision analysis

PURPOSE

The Food and Drug Administration recently approved the use of bladder markers such as BladderChek (NMP22; Matritech, Inc., Newton, MA) and UroVysion (Abbott Laboratories, Abbott Park, IL) for use in screening for bladder cancer. The purpose of this analysis was to assess the cost associated with implementing a widespread screening program using a noninvasive bladder tumor marker.

METHODS

Data for the accuracy of NMP22 in detecting bladder cancer was gathered from a comprehensive literature review. A decision tree analysis was constructed to evaluate the total cost of screening a low and high-risk population for bladder cancer using NMP22. Sensitivity analyses were conducted to evaluate the effect of relaxing the various assumptions in the model.

RESULTS

Application of the model to all men, regardless of the degree of risk, rendered a cost per cancer detected of $783,913, $269,028, and $139,305 for ages 50-59, 60-69, and 70-79 years, respectively. Screening only patients at high-risk for bladder cancer (annual incidence 6%) would yield a cost per cancer detected of $3,310. Incidence of cancer and marker specificity had the highest influence on cost per cancer detected.

CONCLUSIONS

Application of NMP22 to the entire population would render an extremely high cost per cancer detected. However, application to an appropriate high-risk target population could achieve cost per cancer detected comparable to currently used screening programs for prostate, colon, and breast cancer. Further studies are needed to assess the accuracy of bladder tumor markers in detecting bladder cancer in a completely asymptomatic cohort.

[Cost-effectiveness of colorectal cancer screening]

Colorectal cancer (CRC) screening in France is based on a faecal occult blood test every two years in average risk subjects 50-74 years of age while other endoscopic or non-endoscopic screening methods are used in Europe and in the USA. Beside the reduced incidence of and mortality from CRC found in available studies, cost-effectiveness data need to be taken into account. Because of the delay between randomized controlled trials and clinical results, transitional probabilistic models of screening programs are useful for public health policy makers. The aim of the present review was to promote the implementation of cost-effectiveness studies, to provide a guide to analyze cost-effectiveness studies on CRC screening and, to propose a French cost effectiveness study comparing CRC screening strategies. Most of these trials were performed by US or UK authors and demonstrate that the incremental cost-effectiveness ratio varies between 5 000 and 15 000 US dollars/one year life gained, with wide variations: these results were highly dependent on the unit costs of the different devices as well as the predictive values of the screening tests. Although CRC screening programs have been implemented in several administrative districts of France since 2002, and the results of these randomized controlled trials using fecal occult blood have been updated, cost-effectiveness criteria need to be integrated; especially since the results of screening campaigns based on other tools such as flexible sigmoidoscopy should be available in 2007.

Update on the cost-effectiveness of screening for colorectal neoplasia

Colorectal cancer is an ideal target for population screening because it is a prevalent disease with an identifiable precursor lesion that, when treated, favorably alters the natural history of the disease. Several strategies for screening have illustrated efficacy, including fecal occult blood testing, sigmoidoscopy and colonoscopy. Cost-effectiveness analyses have been performed to determine whether the resources required to implement screening are justified by potential gains. The U.S. Preventive Services Task Force recently commissioned a study on the cost-effectiveness of colorectal cancer screening, which revealed that screening was cost-effective compared to no screening. However, it could not be confirmed which strategy would save the most life-years, nor which was most cost-effective. Since publication of this review, several additional cost-effectiveness analyses have been performed. These studies confirm that screening average risk patients at age 50 by a variety of available strategies is likely to be reasonable by current standards for resource utilization, and that either colonoscopy every 10 years (or once at age 65) or the combination of annual fecal occult blood testing with sigmoidoscopy every 5 years are viable alternatives. Additional economic analyses have examined the use of aspirin chemoprophylaxis to prevent colorectal cancer either alone or as an adjunct to screening strategies. These studies reaffirm the cost-effectiveness of colorectal cancer screening, but illustrate that aspirin chemoprophylaxis is unlikely to be associated with gains for which society would be willing to pay. At present, the decision to choose one colorectal screening strategy over another is based on availability of screening modalities, patient and provider preferences, and associated adherence to screening recommendations. Assessment of preference and development of interventions to increase adherence to screening should be a focus of research in the future.