CRC Screening

Earlier CRC screening with colonoscopy, FIT cost-effective ‘irrespective of BMI’

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Regardless of patient sex or BMI, initiating colorectal cancer screening with colonoscopy at age 45 years or with fecal immunochemical testing at age 40 years was cost-effective, according to new research.

In addition, researchers reported CRC screening with colonoscopy at age 40 years was cost-effective in men with class 2 and 3 obesity, whom investigators noted have the highest risk for CRC and all-cause mortality.

study data

“Initiating CRC colonoscopy-based screening at age 45 years is likely to be cost-effective for women and men irrespective of BMI, initiating colonoscopy-based screening at age 40 years may be cost-effective in men with obesity [class 2 to 3], and FIT-based screening may be cost-effective starting at age 40 years in both sexes across the range of BMI,” Aaron Yeoh, MD, and colleagues from the division of gastroenterology and hepatology at Stanford University School of Medicine, wrote in Clinical Gastroenterology and Hepatology.

As obesity is a suspected risk factor for CRC, researchers sought to determine whether intensified CRC screening would be cost-effective in overweight and obese individuals, noting that obesity also is associated with increased morbidity and mortality risks and incremental costs. “Given these competing risks, our aim was to estimate the potential clinical impact and cost-effectiveness of earlier initiation or more intensive CRC screening in overweight and obese persons,” they wrote.

Using a decision analytic model that was recalibrated to avoid double-counting the impact of BMI and birth cohort effect of increasing CRC incidence at younger ages, investigators compared CRC screening initiated at ages 45 or 40 years vs. 50 years in men and women with BMI that ranged from normal weight to class 3 obesity.

They analyzed 10 cohorts, grouped by age and BMI, and studied the impact of annual fecal immunochemical testing (FIT) and colonoscopy every 5 and 10 years. Incremental costs and quality of life-years (QALY) gained were calculated using a payer perspective, with cost-effectiveness defined as no more than $100,000/QALY gained.

Without CRC screening, investigators reported comparable sex-specific total CRC mortality for individuals who were overweight or had class 1 to 3 obesity, “reflecting the counterbalancing of higher CRC risk by lower life expectancy as BMI rises.”

Across BMI categories and sex groups, initiating colonoscopy at age 45 vs. 50 years with routine screening every 10 years through age 75 years cost $33,400 to $85,900/QALY gained. However, researchers reported starting screening at age 40 vs. 45 years with subsequent colonoscopies at 10-year intervals was only cost-effective for men with class 2 or 3 obesity ($93,300/QALY gained vs. $80,400/QALY gained, respectively). In addition, starting FIT at age 40 vs. 45 years cost $22,000/QALY to $58,800/QALY gained for both sexes and across BMI groups.

“Our finding that initiating CRC screening at age 45 years appears cost-effective across

the range of BMI groups, and that even earlier initiation at age 40 years appears cost-effective in men with obesity [class 2 to 3], suggests that the benefits of earlier CRC screening are substantial even when the higher CRC risks in overweight and obese persons are balanced against the higher risk of competing morbidity and mortality, and overweight- and obesity-associated costs that are incurred when CRC death is averted,” researchers wrote. “These findings have implications for CRC screening in overweight and obese persons specifically, and for risk-adjusted CRC screening more generally.”

Million-Strong Study Supports CRC Screening Every 10 Years

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Clinicians following guideline recommendations to screen for colorectal cancer once every 10 years can reassure their patients that the time interval is effective and does not put them at increased risk, conclude US investigators.

Researchers evaluated more than 1.2 million Californians aged 50 to 75 years who were enrolled in a health plan. They compared unscreened individuals with those who had a negative colonoscopy result over a 10-year period.

The results showed that the relative risk of developing colorectal cancer in people with a negative result at 10 years was 46% lower than that for unscreened individuals; the relative risk of colorectal cancer death was 88% lower.

The research was published online December 17 in JAMA Internal Medicine.

Lead author Jeffrey K. Lee, MD, Division of Research, Kaiser Permanente Northern California, Oakland, said in a press release: “Our study shows that, following a colonoscopy with normal findings, there is a reduced risk of developing and dying from colorectal cancer for at least 10 years.”

These findings suggest, said Lee, that physicians “can feel confident” about the guideline-recommended 10-year rescreening interval after a negative colonoscopy in which no colorectal cancer or polyps were found.

“There is now solid evidence supporting that recommendation,” he said.

Senior author Douglas A. Corley, MD, PhD, MPH, also of Kaiser Permanente Northern California, added: “This large study is the first with a high enough number of average-risk individuals to evaluate cancer risks after colonoscopy examinations, compared with no screening.”

The study provides “greater certainty regarding the appropriate timing for rescreening after a negative colonoscopy,” he said.

Asked for comment, Robert A. Smith, PhD, vice president of cancer screening, American Cancer Society in Atlanta, Georgia, said that “the new data show that a 10-year interval is pretty effective.”

Approximately 63% of eligible individuals in the United States undergo colorectal cancer screening, Smith told Medscape Medical News. In the majority of cases, screening is opportunistic, with patients referred as a result of another encounter, he explained.

The current study, said Smith, “probably reinforces in people’s minds the importance of screening…. It’s widely accepted that colorectal cancer screening is a good thing.”

On the other hand, some patients either do not undergo colonoscopy or do not prepare for the procedure properly and end up having to cancel.

“A concern is raised that we have uneven quality of colonoscopy in this country,” he said.

“Just because you’ve had a normal examination doesn’t mean that there aren’t some lesions in there that were overlooked but could potentially grow to become malignancies in the interval before your next examination is due,” Smith continued.

Echoing previous suggestions that “a reasonable and safe thing to do is a fecal immunochemical test, say, at 5 years,” Smith argued that “a high-sensitivity stool test would have the opportunity to pick those [malignancies] up.”

Study Details

Although current guidelines recommend that individuals with a negative colonoscopy result be rescreened after 10 years, the California investigators say the evidence supporting this is “modest” and that that recommendation is based on estimates of colonoscopy sensitivity and the time it takes for adenoma to progress.

Clinicians following guideline recommendations to screen for colorectal cancer once every 10 years can reassure their patients that the time interval is effective and does not put them at increased risk, conclude US investigators.

Researchers evaluated more than 1.2 million Californians aged 50 to 75 years who were enrolled in a health plan. They compared unscreened individuals with those who had a negative colonoscopy result over a 10-year period.

The results showed that the relative risk of developing colorectal cancer in people with a negative result at 10 years was 46% lower than that for unscreened individuals; the relative risk of colorectal cancer death was 88% lower.

The research was published online December 17 in JAMA Internal Medicine.

Lead author Jeffrey K. Lee, MD, Division of Research, Kaiser Permanente Northern California, Oakland, said in a press release: “Our study shows that, following a colonoscopy with normal findings, there is a reduced risk of developing and dying from colorectal cancer for at least 10 years.”

These findings suggest, said Lee, that physicians “can feel confident” about the guideline-recommended 10-year rescreening interval after a negative colonoscopy in which no colorectal cancer or polyps were found.

“There is now solid evidence supporting that recommendation,” he said.

Senior author Douglas A. Corley, MD, PhD, MPH, also of Kaiser Permanente Northern California, added: “This large study is the first with a high enough number of average-risk individuals to evaluate cancer risks after colonoscopy examinations, compared with no screening.”

The study provides “greater certainty regarding the appropriate timing for rescreening after a negative colonoscopy,” he said.

Asked for comment, Robert A. Smith, PhD, vice president of cancer screening, American Cancer Society in Atlanta, Georgia, said that “the new data show that a 10-year interval is pretty effective.”

Approximately 63% of eligible individuals in the United States undergo colorectal cancer screening, Smith told Medscape Medical News. In the majority of cases, screening is opportunistic, with patients referred as a result of another encounter, he explained.

The current study, said Smith, “probably reinforces in people’s minds the importance of screening…. It’s widely accepted that colorectal cancer screening is a good thing.”

On the other hand, some patients either do not undergo colonoscopy or do not prepare for the procedure properly and end up having to cancel.

“A concern is raised that we have uneven quality of colonoscopy in this country,” he said.

“Just because you’ve had a normal examination doesn’t mean that there aren’t some lesions in there that were overlooked but could potentially grow to become malignancies in the interval before your next examination is due,” Smith continued.

Echoing previous suggestions that “a reasonable and safe thing to do is a fecal immunochemical test, say, at 5 years,” Smith argued that “a high-sensitivity stool test would have the opportunity to pick those [malignancies] up.”

Study Details

Although current guidelines recommend that individuals with a negative colonoscopy result be rescreened after 10 years, the California investigators say the evidence supporting this is “modest” and that that recommendation is based on estimates of colonoscopy sensitivity and the time it takes for adenoma to progress.