Cost-effectiveness analysis of colonoscopy and fecal immunochemical testing for colorectal cancer screening in China

A Digital Score Based on Circulating-Tumor-Cells-Derived mRNA Quantification and Machine Learning for Early Colorectal Cancer Detection

Circulating tumor cells (CTCs) serve as valuable biomarkers in tumor circulation, carrying essential primary tumor information. The purification of CTCs from peripheral blood samples and the analysis of their characteristic molecules enable the detection of tumors at an early stage. The noninvasive, continuous, real-time dynamic monitoring provides a promising solution for the timely diagnosis of colorectal cancer (CRC). In this study, we developed a minimally invasive method for CRC early detection to enable accurate screening in a friendly manner for individuals who generally require colonoscopy. The dual-antibody (i.e., anti-EpCAM and anti-EGFR) modified antifouling hydrogel-coated magnetic nanoparticles (pSBMA-MNPs) were prepared for efficient and specific CTC purification. Then, the quantification of 6 RNA transcripts in purified CRC CTCs was performed via droplet digital PCR (ddPCR), and a CRC score was calculated using an extreme gradient boosting model to distinguish CRC from colon polyps and adenomas. A pilot study was conducted to evaluate the clinical potential of the CRC CTC RNA assay in a training cohort (n = 101) and an independent test cohort (n = 65), achieving a diagnostic accuracy of 91.0% in the whole cohort, significantly outperforming serum CEA, CA125, and CA199. Subgroup analysis across CRC stage, age, and tumor location of patients was also performed, and the CRC score exhibited robust performance, demonstrating commendable diagnostic efficacy for CRC detection and promising application in friendly screening individuals that really require colonoscopy.

A Comparison of International Modeling Methods for Evaluating Health Economics of Colorectal Cancer Screening: A Systematic Review

OBJECTIVES

Cost-effectiveness analysis (CEA) is an accepted approach to evaluate cancer screening programs. CEA estimates partially depend on modeling methods and assumptions used. Understanding common practice when modeling cancer relies on complete, accessible descriptions of prior work. This review's objective is to comprehensively examine published CEA modeling methods used to evaluate colorectal cancer (CRC) screening from an aspiring modeler's perspective. It compares existing models, highlighting the importance of precise modeling method descriptions and essential factors when modeling CRC progression.

METHODS

MEDLINE, EMBASE, Web of Science, and Scopus electronic databases were used. The Consolidated Health Economic Evaluation Reporting Standards statement and data items from previous systematic reviews formed a template to extract relevant data. Specific focus included model type, natural history, appropriate data sources, and survival analysis.

RESULTS

Seventy-eight studies, with 52 unique models were found. Twelve previously published models were reported in 39 studies, with 39 newly developed models. CRC progression from the onset was commonly modeled, with only 6 models not including it as a model component.

CONCLUSIONS

Modeling methods needed to simulate CRC progression depend on the natural history structure and research requirements. For aspiring modelers, accompanying models with clear overviews and extensive modeling assumption descriptions are beneficial. Open-source modeling would also allow model replicability and result in appropriate decisions suggested for CRC screening programs.

Cost Effectiveness of Colorectal Cancer Screening Strategies in Middle- and High-Income Countries: A Systematic Review

BACKGROUND AND AIM

Colorectal cancer (CRC) is a significant global health burden, and screening can greatly reduce CRC incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide the cost-effectiveness of CRC screening strategies across countries with different income levels.

METHODS

We searched relevant scientific databases (PubMed, Embase, Ovid, Web of Science, Scopus) from January 1, 2010, to December 31, 2023. We selected English-language studies related to model-based economic evaluations of CRC screening strategies. Information such as the characters of screening tests, model characteristics, and key cost-effectiveness findings were collected. The net monetary benefit approach was used to compare the outcomes of various strategies.

RESULTS

A total of 56 studies were identified, including 46 from high-income countries (HICs), 6 from upper-middle-income countries (UMICs), and 4 from lower-middle-income countries (LMICs). Most annual fecal occult blood tests and fecal immunochemical tests were cost-saving, and colonoscopy every 10 years was cost-saving. Other strategies involving multitarget fecal FIT-DNA detection, computed tomography colonography, and flexible sigmoidoscopy were cost-effective compared with no screening. Newer strategies such as magnetic resonance colonography every 5 years, annual urine metabolomic tests, and fecal bacterial biomarkers were cost-effective compared with no screening.

CONCLUSION

In our updated review, we found that common CRC screening strategies and magnetic resonance colonography continued to be cost-effective compared with no screening. Areas for further development include accurately modeling the natural history of colorectal cancer and obtaining more evidence from UMICs and LMICs.

Age, frequency, and strategy optimization for organized colorectal cancer screening: a decision analysis conducted in China for the years 2023-2038

BACKGROUND

The colorectal cancer mortality rate in China has exceeded that in many developing countries and is expected to further increase owing to multiple factors, including the aging population. However, the optimal policy for colorectal cancer screening is unknown.

METHODS

We synthesized the most up-to-date data using a 12-state Markov model populated with a cohort of Chinese men and women born during 1949-1988, and evaluated 16 conventional and 40 risk-tailored schemes for colorectal cancer screening, considering possible combinations of age (starting at 40 + years and ending at 75 years), frequency, and strategy (standard colonoscopy, fecal immunochemical testing with colonoscopy if positive, or risk-tailored). We projected the incidence and mortality of CRC, cost, and quality-adjusted life years for 2023-2038; and performed incremental cost-effectiveness, probability acceptability, and sensitivity analyses to identify the optimal scheme and the factors affecting this choice.

RESULTS

By 2038, all standard colonoscopy, colonoscopy following fecal immunochemical testing, and risk-tailored schemes were effective in reshaping China's colorectal cancer trajectory, with relative reductions in colorectal cancer incidence and mortality rates of up to 34% and 33.7%, respectively, versus no screening. Two standard colonoscopy, one colonoscopy following fecal immunochemical testing, and four risk-tailored schemes were efficient using a starting age of 40 years. Among these options, a risk-tailored scheme (standard colonoscopy every 5 years for high-risk and annual fecal immunochemical testing screening for moderate-to-low-risk) had a high probability (31.1%) of being optimal (with ≥ 40% uptake for a high-risk population, in particular), given China's present per capita gross domestic product, and would yield the highest gain in quality-adjusted life years in 17 of 31 provinces.

CONCLUSIONS

Our findings suggest the commencement of colorectal cancer screening at 40 years of age in China, and that risk-tailored and some conventional schemes would be effective and cost-efficient. These findings should be valuable for policy-making regarding cancer control and resource allocation.

Yield and Effectiveness of 2-Sample Fecal Immunochemical Test-Based Screening Program for Colorectal Cancer

BACKGROUND AND AIMS

Colorectal cancer (CRC) incidence and mortality of China account for nearly 30% of the global attributable fraction. We aimed to estimate the yield and effectiveness of a 2-sample fecal immunochemical test (FIT)-based screening program in China.

METHODS

Eligible individuals were invited for 2-sample FIT between 2007 and 2021, with positive ones (cutoff 40 μg/g before 2013 and 20 μg/g thereafter) referred for colonoscopy. Participation rates, detection rates, and positive predictive values were calculated. Participants were classified into: FIT+/colonoscopy compliers, FIT+/colonoscopy noncompliers, and FIT- as control subjects. We compared CRC incidence and mortality and calculated the age reaching comparable risk.

RESULTS

Among 246,349 invitees, 150,524 (61.10%) participated in 2-sample FIT, with 16,994 (11.29%) identified as FIT+; 12,816 (75.41%) underwent colonoscopy, yielding a detection rate and positive predictive value of 0.57% and 6.70% for advanced neoplasia, respectively. Median follow-up was 10.58 years. Compared with FIT- participants, CRC incidence and mortality were relatively similar among FIT+/colonoscopy compliers with hazard ratios of 0.94 (95% confidence interval [CI], 0.75-1.19) and 1.62 (95% CI, 1.09 to 2.41) but higher among noncompliers, with hazard ratios of 3.52 (95% CI, 2.85-4.34) and 4.41 (95% CI, 2.96-6.55). Taking CRC incidence and mortality risk of FIT- participants at 50.0 years of age as the benchmark, FIT+/colonoscopy compliers reached same risk at 50.6 and 46.1 years of age, while noncompliers reached the same risk at 38.0 and 37.9 years of age, respectively.

CONCLUSIONS

Two-sample FIT could effectively identify high-risk populations, and colonoscopy compliance is associated with a lower risk of CRC incidence and mortality. This strategy might facilitate CRC screening practice in countries with large populations.

Evaluation of long-term benefits and cost-effectiveness of nation-wide colorectal cancer screening strategies in China in 2020-2060: a modelling analysis

Background

Evidence on the long-term benefits and cost-effectiveness of colorectal cancer (CRC) screening strategies in China remains limited. This modelling study aims to address this issue for various CRC screening strategies in China between 2020 and 2060.

Methods

Using a previously developed microsimulation model (MIMIC-CRC) with Chinese epidemiological data, we evaluated four CRC screening strategies targeting population aged 45-74 years: no screening, colonoscopy every 10 years, biennial faecal immunochemical testing (FIT), and a roll-out FIT screening strategy. Screening coverage (invitation) rates from 5% to 100% were analysed. Single-cohort analysis of 100,000 individuals was conducted to estimate the relative cost-effectiveness of each strategy. A multiple-cohort analysis of 100,000 people aged 40+ over 2020-2060 was conducted to project nation-wide long-term benefits and cost-effectiveness.

Findings

In single-cohort analysis, all strategies yielded reductions in CRC incidence and mortality compared to no screening, with colonoscopy outperforming FIT-based strategies at the same invitation rates. In multiple-cohort analysis, among people over 40 years of age in China over 2020-2060, compared to no screening, at invitation rate of 5%, screening by colonoscopy, biennial FIT and roll-out FIT-based approach were estimated to avert 1.2, 0.4, and 0.3 million incident CRCs and 0.2, 0.1, and 0.1 million CRC-related deaths, respectively, compared to no screening (25.4 million incident CRCs and 4.4 million CRC-related deaths), and this preventive effect enlarged as the screening coverage rate increased. At full coverage, colonoscopy achieved the largest reductions (38.2% lower incidence and 43.2% lower mortality) but required the most resources. Biennial FIT and roll-out FIT-based approach screening was slightly less effective but had significant reduced colonoscopy needs (reduction of 83.8% and 85.2%, respectively) and overall cost (reduction of 23.4% and 37.8%, respectively) compared to colonoscopy screening.

Interpretation

Nation-wide implementation of screening would be effective in reducing the burden of CRC in China. Biennial FIT and roll-out FIT-based screening strategies could prevent incident CRC cases and CRC-related deaths with considerably fewer resources than colonoscopy screening. Efforts should be made to increase the screening coverage in China.

Funding

Chinese Academy of Medical Science Innovation Fund for Medical Science (2022-I2M-1-0031); National Natural Science Foundation of China (82173606; 82273726); Beijing Nova Program of Science and Technology (20230484397).

Clinical diagnostic value of methylated SEPT9 combined with NLR, PLR and LMR in colorectal cancer

PURPOSE

This study aimed to investigate clinical diagnostic values of mSEPT9 combined with NLR, PLR and LMR in CRC.

METHODS

329 subjects composed of 120 CRC patients, 105 polyps patients and 104 healthy participants were prospectively recruited. Clinicopathologic features were collected and analyzed. Plasma samples were collected for mSEPT9, NLR, PLR and LMR test. The sensitivity, specificity and AUC of each biomarker separately or in combination were estimated by the ROC curve.

RESULTS

The levels of NLR, PLR and the PDR of mSEPT9 in CRC patients were significantly higher than those in non-CRC subjects, while LMR was the opposite. The PDR of mSEPT9 in CRC patients was significantly correlated with age, tumor size, tumor stage and M stage. ROC curve analysis demonstrated moderate diagnostic values of mSEPT9, NLR, PLR and LMR in CRC patients with AUC of 0.78 (Se = 0.68, and Sp = 0.89), 0.78 (Se = 0.68, and Sp = 0.83), 0.80 (Se = 0.68, and Sp = 0.81), and 0.77 (Se = 0.72, and Sp = 0.73), respectively. Moreover, combination of these four biomarkers dramatically enhanced the diagnostic accuracy of CRC (AUC = 0.92, Se = 0.90, and Sp = 0.87), especially for CRC patients with large tumors (AUC = 0.95) or distal metastasis (AUC = 0.95).

CONCLUSION

mSEPT9, NLR, PLR and LMR showed the potential to be reliable biomarkers for the diagnosis of CRC. And the combined application of these biomarkers further improved the diagnostic accuracy of CRC significantly.

Cost-effectiveness analysis of single colonoscopy versus single fecal test for colorectal cancer diagnosis and treatment

BACKGROUND AND AIM

Regular endoscopy or fecal immunochemical test (FIT) is ideal for screening colorectal cancer. However, only a limited number of individuals undergo regular screening. This study aimed to compare the cost-effectiveness of a single colonoscopy with a single FIT performed for colorectal cancer screening.

METHODS

A microsimulation model was constructed based on real-world observational data collected from three institutions between 2019 and 2022 that compared colonoscopy-based screening with FIT-based screening. The total costs of diagnosis and treatment of the detected lesions using the two strategies were calculated. The incremental cost-effectiveness ratio (ICER) per life year gained (LYG) of the colonoscopy-based strategy was calculated.

RESULTS

Data from 11 407 patients undergoing colonoscopies and 59 176 patients undergoing FITs were used to establish a model. In the base case analysis of screening strategies, colonoscopy was more cost-effective than FIT (ICER 415 193 yen/LYG). The ICER of the colonoscopy-based strategy among 60- to 69-year-old patients was lowest at 394 200 yen/LYG, whereas that in 20- to 29-year-old patients was highest. Monte Carlo simulations showed that the colonoscopy-based strategy was more cost-effective than the FIT-based strategy (net monetary benefit [NMB]: 5 695 957 yen vs 5 348 253 yen). When the adenoma detection rate in the colonoscopy was over 30% or the positive FIT rate was lower than 8.6% in the FIT-based strategy, the NMB of the colonoscopy-based strategy exceeded that of the FIT-based strategy.

CONCLUSION

In the microsimulation model, colonoscopy is recommended as a one-time screening procedure in patients aged >60 years with >30% ADR or <8.6% positive FIT rate.

Artificial intelligence in colonoscopy: from detection to diagnosis

This study reviews the recent progress of artificial intelligence for colonoscopy from detection to diagnosis. The source of data was 27 original studies in PubMed. The search terms were "colonoscopy" (title) and "deep learning" (abstract). The eligibility criteria were: (1) the dependent variable of gastrointestinal disease; (2) the interventions of deep learning for classification, detection and/or segmentation for colonoscopy; (3) the outcomes of accuracy, sensitivity, specificity, area under the curve (AUC), precision, F1, intersection of union (IOU), Dice and/or inference frames per second (FPS); (3) the publication year of 2021 or later; (4) the publication language of English. Based on the results of this study, different deep learning methods would be appropriate for different tasks for colonoscopy, e.g., Efficientnet with neural architecture search (AUC 99.8%) in the case of classification, You Only Look Once with the instance tracking head (F1 96.3%) in the case of detection, and Unet with dense-dilation-residual blocks (Dice 97.3%) in the case of segmentation. Their performance measures reported varied within 74.0-95.0% for accuracy, 60.0-93.0% for sensitivity, 60.0-100.0% for specificity, 71.0-99.8% for the AUC, 70.1-93.3% for precision, 81.0-96.3% for F1, 57.2-89.5% for the IOU, 75.1-97.3% for Dice and 66-182 for FPS. In conclusion, artificial intelligence provides an effective, non-invasive decision support system for colonoscopy from detection to diagnosis.

Cost-Utility Analysis for Colorectal Cancer Screening According to the Initiating Age of National Cancer Screening Program in Korea

BACKGROUND

This study aimed to identify the most cost-effective strategy for colorectal cancer screening using the fecal immunochemical test (FIT), focusing on screening initiation age in Korea.

METHODS

We designed Markov simulation models targeting individuals aged 40 years or older. Twelve strategies combining screening initiation ages (40, 45, or 50 years old), termination ages (80 or no limit), and intervals (1 or 2 years) were modeled, and the most cost-effective strategy was selected. The robustness of the results was confirmed using one-way and probabilistic sensitivity analyses. Furthermore, the cost-effectiveness of the qualitative and quantitative FIT methods was verified using scenario analysis.

RESULTS

The 2-year interval strategy with a screening age range of 45-80 years was the most cost-effective (incremental cost-utility ratio = KRW 7,281,646/quality adjusted life years). The most sensitive variables in the results were transition rate from advanced adenoma to local cancer and discount rate. The uncertainty in the model was substantially low. Moreover, strategies starting at the age of 40 years were also cost-effective but considered suboptimal. The scenario analysis showed that there was no significant difference in cost-effectiveness between strategies with various relative screening ratio of quantitative and qualitative method.

CONCLUSION

The screening method for advancing the initiation age, as presented in the 2015 revised national screening recommendations, was superior regarding cost-effectiveness. This study provides a new paradigm for the development of a national cancer screening system in Korea, which can be utilized as a scientific basis for economic evaluations.

Genetic testing decision-making experiences within families of colorectal cancer patients: A qualitative study

PURPOSE

Genetic testing is the gold standard for the diagnosis of hereditary colorectal cancer syndromes but is currently inadequate and nonideal. The decision-making processes regarding genetic testing are even less well known. The present study aims to explore the decision-making experience of genetic testing for colorectal cancer patients and their family members.

METHOD

A descriptive qualitative study was employed. Data were collected using individual semi-structured interviews with 5 colorectal cancer patients and 20 family members from November 2020 to April 2021. Interviews were transcribed and analysed using inductive content analysis.

RESULTS

Four categories were identified: 1) the source of information for genetic testing, 2) the differentiated attitudes towards genetic testing, 3) genetic testing decisional needs, and 4) the factors influencing genetic testing decision-making. Colorectal cancer patients and their families engaged in two distinct pathways to genetic testing decisions: direct decision-making and indirect decision-making. Throughout these processes, due to the limited source of information, they had information needs that were met and facilitated genetic testing decision-making.

CONCLUSIONS

Colorectal cancer patients and family members need knowledge related to genetic testing, but they have limited access to information, which prevents them from making informed decisions. Providing decision aid interventions and informational support are significant steps towards addressing the support needs of this population.