Cost-Effectiveness Analysis of Colorectal Cancer Screening: A Systematic Review

Figures & data

Figure 1 The methods to identify studies based on the inclusion criteria.

Note: Adapted from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097.³⁰

Table 1 The Characteristics of the Included Studies

Characteristics	Wong^Citation22	Dinh^Citation23	Ladabaum^Citation24	Sharaf^Citation25	Sharp^Citation26	Dan^Citation27	James^Citation28	Wong^Citation29
Model type	Markov	Archimedes	Markov	Markov	Markov process	Markov	Markov	Markov
Study Population	GP (50 year over)	GP 50–75	GP 50, 65 and older	GP(65–71)	GP(55–74)	GP(50–75)	GP(50–100)	GP(50–70)
Time horizon	25 years	Lifetime	30 years	Lifetime	Lifetime	Lifetime	30 years	20 years
Screening technique	No-screening G-FOBT yearly and 2-year I-FOBT(FIT) yearly and 2-year Colonoscopy 10-year	No-screening FIT/sigmoidoscopy FIT yearly/COLOx1 FIT yearly Sigmoidoscopy 5-year colonoscopy 10-year	No-screening FIT every 2 years FIT yearly MT-s DNA every 3 years Colonoscopy 10-year	No-screening FS once FOBT yearly FS every 5 years FIT yearly Colonoscopy every 10 years FS 5-year+ FIT yearly	No-screening biennial G FOBT at ages (55–74) biennial FIT at ages (55–74) FSIG once at age 60	No-screening, FIT early, barium enema 5-year, sigmoidoscopy 5-year, sigmoidoscopy 5-year+ FIT early, stool DNA every 5 years, single colonoscopy colonoscopy 10-year, colonography10-year, FIT early+ colonoscopy 10-year	No-screening FIT yearly colonoscopy 10-year stool DNA3-year sigmoidoscopy5-year	No-screening FS5-year at ages 50–70 for male and female Colonoscopy 10-year at ages 50–60–70 for male and female FS5-year at ages 50–55 (female) FS5-year at ages 50–65 (female) FS5-year at ages 50–70 (female)+colonoscopy10-year
Perspective	Third-party payer (healthcare service provider)	Societal	Third-party payer	Third-party payer	Third-party payer	Societal	Societal	Third-party payer (healthcare service provider)
Out-come Data sources	LYs or QALYs/experimental studies	QALYs/Systematic review	QALYs/Observational and experimental studies	QALYs/Systematic review	QALYs/Systematic review	QALYs/Systematic review	QALYs/review of literature	LYs/experimental studies
Type of cost included	Direct	Direct	Direct	Direct	Direct	Indirect- Direct	Indirect- Direct	Direct
Source of screening cost	Hong Kong Government Printers (Government Gazette)	Medicare	Medicare payment	Medicare	DRG-2 article	Governments restructured hospitals in Singapore	Medicare and private insurance	Hong Kong Government Printers (Government Gazette)
FOBT $PPP	NR	NR	NR	25.25	10	NR	NR	NR
FIT $PPP	NR	2.6	19	25.25	15	33	22	NR
Barium enema	NR	NR	NR	NR	NR	115.3	NR	NR
Colonoscopy $PPP	1351	570.3	1416	708.07	842	708.1	1075	1351
Sigmoidoscopy $PPP	NR	184.4	NR	185.52	194	219.6	185.8	368
Sigmoidoscopy +FIT $PPP	NR	NR	NR	NR	NR	NR	NR	NR
Stool DNA	NR	NR	661	NR	NR	329.3	NR	NR
Virtual Colonography $PPP	NR	NR	NR	NR	550	866.15	NR	713
FIT+ Colonoscopy $PPP	NR	NR	NR	NR	NR	NR	NR	NR
Polypectomy, $PPP	267	172	NR	1112.05	NR	NR	NR	267
Treatment of perforation, $PPP	15002	NR	23058	15652.14	13215	26346.7	NR	15002
Indirect costs, $	Wong^Citation22	Dinh^Citation23	Ladabaum^Citation24	Sharaf^Citation25	Sharp^Citation26	Dan^Citation27	James^Citation28	Wong^Citation29
Screen program cost * $PPP	NR	NR	NR	NR	NR	4.17	NR	NR
Transport and wage loss $PPP	NR	NR	NR	NR	NR	1207.6	NR	NR
Localized, $PPP	NR	NR	3599	2482.1	47129	14106.7	2831	23014
Regional, $PPP	NR	NR	4795	3307.6	62229	25084.3	3080	37986
Distant, $PPP	NR	NR	99381	78866.7	46380	46930.1	12317	99761
Side effects	Bleeding or perforation	NR	Perforation- major hemorrhage	Perforation- hemorrhage	Major bleeding- bowel perforation- deaths due to perforation	Major bleeding- Bowel Perforation- Deaths due to perforation	NR	Bleeding or perforation
Currency (type and year)	U.S dollar-2009	U.S dollar- 2010	U.S dollars 2015	U.S dollar- 2010	€ 2008	U.S dollar- 2009	U.S dollar 2014	U.S dollar-NR
Discount rate	3.5%	3%	3%	3%	4%	3%	3%	3%
Approach to expressing uncertainty	Deterministic and PSA	One-way sensitivity	One-way and multiway sensitivity	One-way sensitivity analyses	PSA and One-way sensitivity analyses	One-way and multi-way sensitivity	One-way and two-way sensitivity analyses, PSA	1-way sensitivity
Important variables in sensitivity analysis	Model parameters And outputs (compliance rates of screening, utilities, discount rate)	Compliance rates, interval between FIT screenings, performance characteristics of FIT and colonoscopy, costs of FIT, colonoscopy, and CRC treatments, and discount rate	All model inputs: costs- utility, sensitivity, specificity, side effect, interval screening	Costs of the tests, the costs of CRC care, the risk of CRC	Discount rate, costs of screening tests, costs of managing colorectal cancer	Incidence of colorectal cancer, secondary and tertiary adherence, and cost of colonoscopy, specificity and sensitivity of tests	All inputs model (specificity and sensitivity of tests, costs of the tests	Compliance rates of screening, specificity and sensitivity of tests, costs of the tests

Note: *The cost of screening program includes: screening center manpower staffing/training/case-tracking/registry/public education audit/quality control.

Abbreviations: GP, general population; FIT, fecal immunochemical test; MT-s DNA, multi-target stool DNA; FS once, flexible sigmoidoscopy once; FOBT, fecal occult blood test; QALYs, quality-adjusted life-year; LYS, life years saved; NR, not reported; PSA, probabilistic sensitivity analysis; CRC, colorectal cancer; NR, not reported.

Table 2 The Incremental Cost-Effectiveness Ratios of Different Techniques for CRC, in Contrast to the No-Screening Method

Screening Test	Study/Reference
	Wong^Citation22	Dinh^Citation23	Ladabaum^Citation24	Sharaf^Citation25	Sharp^Citation26	Dan^Citation27	Kingsley^Citation28	Wong^Citation29
FIT 2-year	4328	-	−11391	-	1306	-	-	-
FIT yearly	4587	−16169	−7970	−7243	-	34580	−6005	-
FIT+COLOx1^a	-	−12695	-	-	-	-	-	-
FIT+sigmoidoscopy	-	−12243	-	−1988	-	47205	-	-
Sigmoidoscopy once	-	-	-	−11,712	1257	25981	-	-
Sigmoidoscopy 5-year	-		-	−3330	-	45448	−3109	40237
Colonoscopy 10-year	5265	−10400	15283	2959	-	38745	3316	22391
Single Colonoscopy	-	-	-	-	-	43911	-	-
Stool DNA	-	30014	-	-	-	48205	16046	-
Virtual colonography 5-y	-	-	-	-	-	49830	-	-

Notes: The negative ICER indicates that the new technique is less costly and more effective. The positive ICERs refer to those techniques that are more costly and more effective; both numerators and denominators are positive.

Abbreviation: ^aCOLOx1, colonoscopy once.

Table 3 The Calculated Incremental Cost-Effectiveness Ratios When Using FIT Yearly vs FIT Every 2-Year, and FOBT Yearly

Author/Technique	C	Q	ICER	Threshold	Optimal Strategy
Sharaf^Citation25
FIT yearly	2090	18.7456	−9327	$US 50000	FIT yearly was dominant
FOBT yearly	2187	18.7352
Sharp^Citation26
FIT 2-yearly	1443	10.984	563	WHO Recommendation	FIT 2-yearly was cost-effective ^a
FOBT 2-yearly	1434	10.968
Wong^Citation22
FIT yearly	7371	15.5491	−1504	$US 50000	FIT yearly was dominant
FOBT yearly	7845	15.2339
Wong^Citation22
FIT 2-yearly	6606	15.4203	1328	$US 50000	FIT 2-yearly was cost-effective
FOBT 2-yearly	6136	15.0687
Ladabaum^Citation24
FIT yearly	2450	18.747	33167	$US 50000	FIT yearly was cost-effective
FIT 2-year	2251	18.741

Notes: In this table, for each study, the first row shows the new technique that is compared with the old technique, presented in the second row. The negative ICER indicates that the new technique is less costly and more effective. The positive ICERs refer to those techniques that are more costly and more effective; both numerators and denominators are positive. ^aBased on the context threshold.

Abbreviations: C, costs per person ($PPP); Q, QALYs (quality-adjusted life-year); ICER, incremental cost-effectiveness ratio; FOBT, fecal occult blood testing; FIT, fecal immunochemical testing.

Table 4 The Calculated Incremental Cost-Effectiveness Ratios When Using FIT Alone vs Flexible Sigmoidoscopy (FS)

Author/Technique	C	Q	ICER	Threshold	Optimal Strategy
Dinh^Citation23
FIT yearly	2028.2	15.771	−15896	$US 50000	FIT yearly was dominant
FS 5-year	2425.6	15.746
Sharaf^Citation25
FIT yearly	2090	18.7456	−39167	$US 50000	FIT yearly was dominant
FS 5-year	2419	18.7372
Dan^Citation27
FIT yearly	378.73	16.393	60370	$US 50000	FIT yearly was dominated
Single FS	318.36	16.392
Kingsley^Citation28
FIT yearly	1607	19.506	−11370	$US 50000	FIT yearly was dominant
FS 5-year	1914	19.479
Sharaf^Citation25
FIT yearly	2090	18.7372	−5920	$US 50000	FIT yearly was dominant
FS once	2341	18.6948
Dan^Citation27
FIT yearly	378.73	16.393	88920	$US 50000	FIT yearly was dominated
FS 5-year	467.65	16.394

Notes: In this table, for each study the first row shows the new technique that is compared with the old technique, written in the second row. The negative ICER indicates that the new technique is less costly and more effective.

Abbreviations: C, costs per person ($PPP); Q, QALYs (quality-adjusted life-year); ICER, incremental cost-effectiveness ratio; FOBT, fecal occult blood testing; FIT, fecal immunochemical testing; FS 5-year, flexible sigmoidoscopy every 5 years; FS once flexible sigmoidoscopy once in lifetime.

Table 5 The Calculated Incremental Cost-Effectiveness Ratios When Using FOBT Alone vs Flexible Sigmoidoscopy (FS)

Author/Technique	C	Q	ICER	Threshold	Optimal Strategy
Sharaf^Citation25
FOBT yearly	2178	18.7352	120500	$US 50000	FOBT yearly was dominated
Sigmoidoscopy 5-year	2419	18.7372
Sharp^Citation26
FOBT 2-year	1434	10.968	19500	WHO Recommendation	FOBT 2-year was cost-effective ^a
Sigmoidoscopy once	1395	10.966
Sharaf^Citation25
FOBT yearly	2178	18.7352		$US 50000	FOBT yearly was dominant
(FS Once)Sigmoidoscopy once	2341	18.6948	−4035

Notes: In this table, for each study, the first row shows the new technique that is compared with the old technique, written in the second row. The negative ICER indicates that the new technique is less costly and more effective. The positive ICERs refer to those techniques that are more costly and more effective; both numerators and denominators are positive. ^aBased on the context threshold.

Abbreviations: C, costs per person ($PPP); Q, QALYs (quality-adjusted life-year); ICER, incremental cost-effectiveness ratio; FOBT, fecal occult blood testing yearly; FIT, fecal immunochemical testing yearly; FS once, flexible sigmoidoscopy once in lifetime.

Table 6 The Calculated Incremental Cost-Effectiveness Ratios When Using FIT+ Sigmoidoscopy vs FIT

Author/Technique	C	Q	ICER	Threshold	Optimal Strategy
Dinh^Citation23
FIT early+ sigmoidoscopy 5-year	2209.1	15.787	11306	$US 50000	FIT early+ FS 5-year was cost-effective ^a
FIT yearly	2028.2	15.771
Sharaf^Citation25
FS 5-year + FIT yearly	2492	18.7469	309231	$US 50000	FS 5-year + FIT yearly was dominated
FIT yearly	2090	18.7456
Dan^Citation27
FS 5-year + IFOBT yearly	570.85	16.396	64040	$US 50000	FS 5-year + IFOBT yearly was dominated
IFOBT yearly	378.73	16.393

Notes: In this table, for each study, the first row shows the new technique that is compared with the old technique, written in the second row. The negative ICER indicates that the new technique is less costly and more effective. The positive ICERs refer to those techniques that are more costly and more effective; both numerators and denominators are positive. ^aBased on the context threshold.

Abbreviations: C, costs per person ($PPP); Q, QALYs (quality-adjusted life-year); ICER, incremental cost-effectiveness ratio; FOBT, fecal occult blood testing; FIT, fecal immunochemical testing.

Table 7 The Calculated Incremental Cost-Effectiveness Ratios When Using Colonoscopy vs FIT and FOBT

Author/Technique	C	Q	ICER	Threshold	Optimal Strategy
Dinh^Citation23
Colonoscopy 10-year	2384.3	15.79	17805	$US 50000	Colonoscopy 10-year was cost-effective ^a
FIT yearly	2028.2	15.77
Ladabaum^Citation24
Colonoscopy 10-year	4248	18.746	443778	$US 50000	Colonoscopy 10-year was dominated
FIT 2-year	2251	18.741
Sharaf^Citation25
Colonoscopy 10-year	2871	18.7443	75165	$US 50000	Colonoscopy 10-year was dominated
FOBT yearly	2187	18.7352
Wong^Citation22
Colonoscopy 10-year	6911	15.3586	−7490	$US 50000	Colonoscopy 10-year was dominant
G-FOBT yearly	7845	15.2339
Kingsley^Citation28
Colonoscopy 10-year	2474	19.517	78818	$US 50000	Colonoscopy 10-year was dominated
FIT yearly	1607	19.506

Notes: In this table, for each study, the first row shows the new technique that is compared with the old technique, written in the second row. The negative ICER indicates that the new technique is less costly and more effective. The positive ICERs refer to those techniques that are more costly and more effective; both numerators and denominators are positive. ^aBased on the context threshold.

Abbreviations: C, costs per person ($PPP); Q, QALYs (quality-adjusted life-year); ICER, incremental cost-effectiveness ratio; G-FOBT, guaiac fecal occult blood testing; FIT, fecal immunochemical testing.

Table 8 The Calculated Incremental Cost-Effectiveness Ratios When Using Colonoscopy vs FIT + Sigmoidoscopy

Author/Technique	C	Q	ICER	Threshold	Optimal Strategy
Dinh^Citation23
Colonoscopy 10 year	2384.3	15.79	58400	$US 50000	Colonoscopy 10-year was dominated
FIT yearly+ sigmoidoscopy 5-year	2209.1	15.787
Dan^Citation27
Colonoscopy 10-year	899.08	16.406	32823	$US 50000	Colonoscopy 10-year was cost-effective ^a
Sigmoidoscopy 5-year + IFOBT yearly	570.85	16.396

Notes: In this table, for each study, the first row shows the new technique that is compared with the old technique, written in the second row. The positive ICERs refer to those techniques that are more costly and more effective; both numerators and denominators are positive. ^aBased on the context threshold.

Abbreviations: C, costs per person ($PPP); Q, QALYs (quality-adjusted life-year); ICER, incremental cost-effectiveness ratio; IFOBT, fecal occult blood testing; FIT, fecal immunochemical testing.

Table 9 The Calculated Incremental Cost-Effectiveness Ratios When Using Colonoscopy vs Stool DNA

Author/Technique	C	Q	ICER	Threshold	Optimal Strategy
Ladabaum^Citation24
Colonoscopy 10-year	4248	18.7455	−323438	$US 50000	Colonoscopy 10-year was dominant
MT-s DNA 3-year	5283	18.7423
Dan^Citation27
Colonoscopy 10-year	899.08	16.406	28432	$US 50000	Colonoscopy 10-year was cost-effective ^a
Stool DNA 5-year	614.76	16.396
Kingsley^Citation28
Colonoscopy 10-year	2474	19.517	−111600	$US 50000	Colonoscopy 10-year was dominant
Stool DNA 3-year	3590	19.507

Notes: In this table, for each study, the first row shows the new technique that is compared with the old technique, written in the second row. The negative ICER indicates that the new technique is less costly and more effective. The positive ICERs refer to those techniques that are more costly and more effective; both numerators and denominators are positive. ^aBased on the context threshold.

Abbreviations: C, costs per person ($PPP); Q, QALYs (quality-adjusted life-year); ICER, incremental cost-effectiveness ratio; MT-S DNA 3-year, multi-target stool DNA every 3-year.

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