Colorectal cancer (CRC) remains a common tumor, and cost-effectiveness of the interventions used to reduce the burden of this cancer is of great interest. Costs associated with CRC include interventions for primary prevention of the disease as well as screening and treatment. The cost of primary prevention for CRC could be variable as different individual factors could be considered preventive such as changes in lifestyle issues, including obesity, lack of exercise or change of diet.1 Screening for CRC may eventually be cost-effective (most commonly includes testing stool for blood and either sigmoidoscopy or colonoscopy), but often requires a significant investment first by insurance companies or governments.2 Treatment of CRC with chemotherapy has risen in cost, particularly with the addition of newer biological therapies.2
Ginsberg and colleagues3 report on research recently published discussing regional cost-effectiveness estimates of prevention, screening and treatment interventions for CRC in different regions. A standardized WHO (World Health Organization)-CHOICE (CHOosing Interventions that are Cost Effective) methodology was used and the authors used a CRC model to provide estimates of screening and treatment effectiveness with intervention effectiveness determined via a population state-transition model (PopMod). PopMod simulated a sub-regional population for births, deaths and disease epidemiology; costs for procedures and treatment were estimated as well.3
- The WHO-CHOICE framework is based on sectoral, population-level cost-effectiveness analyses based on a generalized cost-effectiveness analysis framework
- The analysis is characterized by the assessment of costs and effects against a reference scenario defined as the absence of interventions against the targeted disease (the “null” scenario)
- Costs and effects of specific interventions for CRC were modeled at the population level in 14 WHO regions
- Interventions included those for repeated screening followed by removal of polyps or potentially cancerous lesions (annual and biannual fecal occult blood test [FOBT]), sigmoidoscopy every 5 years, colonoscopy every 10 years, and annual FOBT with sigmoidoscopy every 5 years or aforementioned followed by treatment
- Additional interventions included FOBT, sigmoidoscopy, colonoscopy and annual FOBT with sigmoidoscopy combined followed by polyp and lesion removed for persons aged 50 years or the aforementioned followed by treatment
- Treatment interventions for the study included combinations of surgery, radiotherapy and chemotherapy
- Prevention interventions for this study included increasing fruit and vegetable consumption by means of mass media campaign
Other interventions with less-studied efficacy included the use of digital rectal exams (DREs) with and without treatment
Double contrast barium enema as an intervention was not included; exercise, smoking cessation and the use of aspirin or folic acid were not considered as potential interventions because of inadequate level of evidence to meet the WHO-CHOICE criteria
The costs of the 10 year intervention implementation period was discounted at 3% and expressed in international dollars at year 2000 price levels (equivalent of $1 in US purchasing power). Cost-effectiveness for developed countries report a wide range of costs per life year for colorectal cancer interventions compared to that of treatment alone.
The authors concluded that the following policy recommendations could be made from the study results:
- In high income, low mortality and high existing treatment coverage subregions, both the incremental (the additional cost per disability-adjusted life year [DALY] gained) of adding a screening intervention to the existing treatment provided demonstrate the cost-effective nature of the screening intervention. However, no specific intervention was shown to be dominant in their results.
- In low income, low mortality subregions with existing treatment coverage of approximately 50%, expanding treatment with or without combining it with screening interventions appeared to be cost-effective or very cost-effective; discontinuation of treatment for funding of screening programs would not be cost-effective.
- In low income subregions with low income, low mortality and low treatment levels, the most appropriate strategy would be to provide resources to treat persons with CRC versus the implementation of a screening program.
- The fruit and vegetable campaign gained the fewest DALYs of any intervention, although it was very cost effective in the subregion with high income, low mortality and high existing treatment coverage. It was not effective at all in the low income, low mortality and low treatment levels subregion
Although definitive guidelines for prevention, screening and treatment of CRC are not yet standard of care for all subregions, included in this study, the results do point out that screening programs should be expanded in developed regions and treatment intervention programs should be implemented in regions with low treatment coverage.
- Qasim A, O’Morain C. Primary prevention of colorectal cancer: are we closer to reality? Eur J Gastroenterol Hepatol. 2010 Jan;22:9-17. doi: 10.1097/MEG.0b013e328330d0d6. Link to abstract at http://journals.lww.com/eurojgh/pages/articleviewer.aspx?year=2010&issue=01000&article=00002&type=abstract.
- Landsdorp-Volgelaar I, van Ballegooijen M, Zauber AG, et al. Effect of rising chemotherapy costs on the cost savings of colorectal cancer screening. J Natl Cancer Inst. 2009; 101: 1412-22. doi:10.1093/jnci/djp319. Link to abstract at: http://www.ncbi.nlm.nih.gov/pubmed/19779203.
- Ginsberg GM, Lim SS, Lauer JA, et al. Prevention, screening and treatment of colorectal cancer: a global and regional generalized cost effectivenes analysis. Cost Eff Resour Alloc. 2010; 8: 2.[Epub ahead of print]. doi:10.1186/1478-7547-8-2. Link to full text article at: http://www.resource-allocation.com/content/8/1/2.