Adding postpolypectomy surveillance to fecal immunochemical testing is not cost-effective

1. Fecal immunochemistry testing (FIT) screening alone reduced mortality from colorectal cancer (CRC).

2. Adding postpolypectomy surveillance colonoscopy was not found to be cost effective based on the Dutch CRC screening program.

Evidence Rating Level: 2 (Good)

Study Rundown: CRC screening programs have been shown to significantly reduce mortality from CRC. Some countries have implemented CRC screening programs in addition to existing colonoscopy surveillance programs; however, the benefit of surveillance by colonoscopy is unclear. The authors of this study aimed to assess whether colonoscopy surveillance in a Dutch screening setting provides additional benefits in terms of cost effectiveness. In general, postpolypectomy surveillance colonoscopy was not found to be cost effective. This study has several limitations. First, the study was performed in a low risk population, which suggests that it may not be translated to higher risk population groups. Additionally, the trial was also limited by the number of colonoscopy surveillance strategies possible to evaluate. Overall, the results of the study suggest that keeping including postpolypectomy surveillance colonoscopy does not provide a cost effective benefit with respect to CRC based on the Dutch incremental cost-effectiveness ratios (ICER).

Click to read the study in the Annals of Internal Medicine

Relevant Reading: Cost Effectiveness of Screening Colonoscopy Depends on Adequate Bowel Preparation Rates – A Modeling Study

In-Depth [retrospective cohort]: Study participants were selected from the Dutch CRC screening program. Inclusion criteria consisted of asymptomatic persons aged 55 to 75 years without a previous CRC diagnosis. The authors conducted a simulation where they compared FIT screening alone with FIT screening in addition to colonoscopy surveillance. Additionally, the authors examined the effect of extending colonoscopy surveillance intervals. It was found that FIT screening alone reduced CRC mortality by 50.4%. While adding colonoscopy reduced the CRC mortality to 52.1%, the lifetime demand for colonoscopy from significantly increased from 335 to 543 colonoscopies per 100 persons (62%). This increase in colonoscopy resulted in an additional cost of €68 000 for an increase of 0.9 life years. Generally, the cost of colonoscopy surveillance exceed the Dutch willingness-to-pay threshold of €36 602 per life-year gained. However, they found that extending the interval of colonoscopy to 5 years would decrease demand by 41.7% while still providing a beneficial reduction in CRC mortality of 51.8%.

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