Endoscopy 2008; 40(5): 414-421
DOI: 10.1055/s-2007-995565
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Cost-effectiveness of capsule endoscopy in screening for colorectal cancer

C.  Hassan1 , A.  Zullo1 , S.  Winn1 , S.  Morini1
  • 1Gastroenterology and Digestive Endoscopy Unit, “Nuovo Regina Margherita” Hospital, Rome, Italy
Weitere Informationen

Publikationsverlauf

submitted 16 June 2007

accepted after revision 1 January 2008

Publikationsdatum:
27. Februar 2008 (online)

Background and study aims: Capsule endoscopy (Pillcam Colon) has recently shown acceptable accuracy in detecting colonic lesions when compared with colonoscopy. The aim of this analysis is to provide a model to assess the cost and effectiveness of population-based screening for colorectal cancer (CRC) using capsule endoscopy and to compare the cost-effectiveness with that of a colonoscopy screening program.

Methods: The cost-effectiveness of two screening strategies using colonoscopy or capsule endoscopy were compared by a computer model based on a Markov process. In this model, a hypothetical population of 100 000 individuals aged 50 years and over, undergoes a 10 yearly screening procedure. Different thresholds for postcapsule polypectomy referral were simulated.

Results: At baseline, the incremental cost-effectiveness (compared with no screening) of colonoscopy and capsule endoscopy was $ 16 165 and $ 29 244 per life-year saved, respectively. When equal compliance was simulated, the colonoscopy program was more effective and less costly than a strategy based on capsule endoscopy. When simulating an initial compliance to capsule endoscopy 30 % better than colonoscopy, capsule endoscopy became the more effective and more cost-effective option. A 20 % better compliance was sufficient when a higher accuracy of capsule endoscopy for polyps was assumed. A 6 mm threshold for polypectomy referral was associated with a substantial cost reduction in the capsule endoscopy program with only a small loss of efficacy.

Conclusions: The cost-effectiveness of capsule endoscopy depends mainly on its ability to improve compliance to CRC screening.

References

  • 1 Ries L A, Wingo P A, Miller D S. et al . The annual report to the nation on the status of cancer, 1973 - 1997, with a special section on colorectal cancer.  Cancer. 2000;  88 2398-2424
  • 2 Atkin W S, Morson B C, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas.  N Engl J Med. 1992;  326 658-662
  • 3 Winawer S J, Zauber A G, Ho M N. et al . Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.  N Engl J Med. 1993;  329 1977-1981
  • 4 Citarda F, Tomaselli G, Capocaccia R. et al . Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence.  Gut. 2001;  48 812-815
  • 5 Nadel M R, Blackman D K, Shapiro J A. et al . Are people being screened for colorectal cancer as recommended? Results from the National Health Interview Survey.  Prev Med. 2002;  35 199-206
  • 6 Boyle P, Autier P, Bartelink H. et al . European Code Against Cancer and scientific justification: third version (2003).  Ann Oncol. 2003;  14 973-1005
  • 7 Schoofs N, Devière J, Munoz-Navaz M, Fernandez-Urien I. PillCam colon capsule endoscopy compared to colonoscopy in detection of colon polyps and cancers. Interim analysis of a prospective multi-center trial.  Gut. 2007;  56 (Suppl) A71
  • 8 Schoofs N, Devière J, Van Gossum A. PillCam colon capsule endoscopy compared with colonoscopy for colorectal tumor diagnosis: a prospective pilot study.  Endoscopy. 2006;  38 963-970
  • 9 Eliakim R, Fireman Z, Gralnek I M. et al . Evaluation of the PillCam Colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study.  Endoscopy. 2006;  38 963-970
  • 10 Pignone M, Saha S, Hoerger T. et al . Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U. S. Preventive Services Task Force.  Ann Intern Med. 2002;  137 96-104
  • 11 Ladabaum U, Song K, Fendrick A M. Colorectal neoplasia screening with virtual colonoscopy: when, at what cost, and with what national impact?.  Clin Gastroenterol Hepatol. 2004;  2 554-563
  • 12 DiSario J A, Foutch P G, Mai H D. et al . Prevalence and malignant potential of colorectal polyps in asymptomatic, average-risk men.  Am J Gastroenterol. 1991;  86 941-945
  • 13 Vatn M H, Stalsberg H. The prevalence of polyps of the large intestine in Oslo: an autopsy study.  Cancer. 1982;  49 819-825
  • 14 Rickert R R, Auerbach O, Garfinkel L. et al . Adenomatous lesions of the large bowel: an autopsy survey.  Cancer. 1979;  43 1847-1857
  • 15 Arminski T C, McLean M D. Incidence and distribution of adenomatous polyps of the colon and rectum based on 1,000 autopsy examinations.  Dis Colon Rectum. 1964;  7 249-261
  • 16 Stemmermann G N, Heilbrun L K, Nomura A. et al . Adenomatous polyps and atherosclerosis: an autopsy study of Japanese men in Hawaii.  Int J Cancer. 1986;  38 789-794
  • 17 Eide T J. The age-, sex-, and site-specific occurrence of adenomas and carcinomas of the large intestine within a defined population.  Scand J Gastroenterol. 1986;  21 1083-1088
  • 18 Johnson D A, Gurney M S, Volpe R J. et al . A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an age-related risk.  Am J Gastroenterol. 1990;  85 969-974
  • 19 Yee J, Akerkar G A, Hung R K. et al . Colorectal neoplasia: performance characteristics of CT colonography for detection in 300 patients.  Radiology. 2001;  219 685-692
  • 20 Williams A R, Balasooriya B A, Day D W. Polyps and cancer of the large bowel: a necropsy study in Liverpool.  Gut. 1982;  23 835-842
  • 21 Clark J C, Collan Y, Eide T J. et al . Prevalence of polyps in an autopsy series from areas with varying incidence of large-bowel cancer.  Int J Cancer. 1985;  36 179-186
  • 22 Koretz R L. Malignant polyps: are they sheep in wolves' clothing?.  Ann Intern Med. 1993;  118 63-68
  • 23 Loeve F, Boer R, Zauber A G. et al . National Polyp Study data: evidence for regression of adenomas.  Int J Cancer. 2004;  111 633-639
  • 24 Hofstad B, Vatn M, Larsen S. et al . Growth of colorectal polyps: redetection and evaluation of unresected polyps for a period of three years.  Gut. 1996;  39 449-456
  • 25 Hoff G, Foerster A, Vatn M H. et al . Epidemiology of polyps in the rectum and colon. Recovery and evaluation of unresected polyps 2 years after detection.  Scand J Gastroenterol. 1986;  21 853-862
  • 26 Stryker S J, Wolff B G, Culp C E. et al . Natural history of untreated colonic polyps.  Gastroenterology. 1987;  93 1009-1013
  • 27 Welin S, Youker J, Spratt Jr J S. The rates and patterns of growth of 375 tumors of the large intestine and rectum observed serially by double contrast enema study (Malmö Technique).  Am J Roentgenol Radium Ther Nucl Med. 1963;  90 673-687
  • 28 Ries L A, Kosary C L, Hankey B F. et al .SEER Cancer Statistics Review, 1973 - 1994. Bethesda, MD; National Institutes of Health, National Cancer Institute, NIH Publication No. 97 - 2789 1997: 117-166
  • 29 Pickhardt P J, Hassan C, Laghi A. et al . Cost-effectiveness of colorectal cancer screening with computed tomography colonography: the impact of not reporting diminutive lesions.  Cancer. 2007;  109 2213-2221
  • 30 Chen C D, Yen M F, Wang W M. et al . A case-cohort study for the disease natural history of adenoma-carcinoma and de novo carcinoma and surveillance of colon and rectum after polypectomy: implication for efficacy of colonoscopy.  Br J Cancer. 2003;  88 1866-1873
  • 31 Ladabaum U, Chopra C L, Huang G. et al . Aspirin as an adjunct to screening for prevention of sporadic colorectal cancer. A cost-effectiveness analysis.  Ann Intern Med. 2001;  135 769-781
  • 32 National Cancer Institute .Web site: Using Fast Stats. http://seer.cancer.gov/faststats/. Accessed at www.cdc.gov on 24 April 2007
  • 33 Hixson L J, Fennerty M B, Sampliner R E. et al . Prospective blinded trial of the colonoscopic miss-rate of large colorectal polyps.  Gastrointest Endosc. 1991;  37 125-127
  • 34 Rex D K, Cutler C S, Lemmel G T. et al . Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies.  Gastroenterology. 1997;  112 24-28
  • 35 Kirschner C G, Davis S J, Evans D. et al .Current procedural Terminology: CPT. Chicago; American Medical Assoc 1999
  • 36 Levin T R, Zhao W, Conell C. et al . Complications of colonoscopy in an integrated health care delivery system.  Ann Intern Med. 2006;  145 880-886
  • 37 Seare S, Speirs L, Bernard S P. et al .DRG Guide. Salt Lake City; Medicode 1997
  • 38 Gerson L, Lin O S. Cost-benefit analysis of capsule endoscopy compared with standard upper endoscopy for the detection of Barrett's esophagus.  Clin Gastroenterol Hepatol. 2007;  5 319-325
  • 39 Taplin S H, Barlow W, Urban N. et al . Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care.  J Natl Cancer Inst. 1995;  87 417-426
  • 40 Fireman B H, Quesenberry C P, Somkin C P. et al . Cost of care for cancer in a health maintenance organization.  Health Care Financ Rev. 1997;  18 51-76
  • 41 Brown M L, Riley G F, Potosky A L. et al . Obtaining long-term disease specific costs of care: application to Medicare enrolees diagnosed with colorectal cancer.  Med Care. 1999;  37 1249-1259
  • 42 Church J M. Clinical significance of small colorectal polyps.  Dis Colon Rectum. 2004;  47 481-485
  • 43 Odom S R, Duffy S D, Barone J E. et al . The rate of adenocarcinoma in endoscopically removed colorectal polyps.  Am Surg. 2005;  71 1024-1026
  • 44 Butterly L F, Chase M P, Pohl H, Fiarman G S. Prevalence of clinically important histology in small adenomas.  Clin Gastroenterol Hepatol. 2006;  4 343-348
  • 45 Gschwantler M, Kriwanek S, Langner E. et al . High-grade dysplasia and invasive carcinoma in colorectal adenomas: a multivariate analysis of the impact of adenoma and patient characteristics.  Eur J Gastroenterol Hepatol. 2002;  14 183-188
  • 46 National Center for Health Statistics .National Vital Statistics Report. 2003 http://Accessed at www.cdc.gov on 24 April 2007
  • 47 .Life tables. Vital statistics of the United States. Preprint of Volume II, mortality, part A, section 6. Hyattsville, MD; National Center for Health Statistics 1998
  • 48 Hassan C, Zullo A, Laghi A. et al . Colon cancer prevention in Italy: cost-effectiveness analysis with CT colonography and endoscopy.  Dig Liver Dis. 2007;  39 242-250
  • 49 Hassan C, Laghi A, Pickhardt P J. et al . Projected impact of colorectal cancer screening with computerized tomographic colonography on current radiological capacity in Europe.  Aliment Pharmacol Ther. 2008;  27 366-374
  • 50 Sonnenberg A, Delco F, Inadomi J M. Cost-effectiveness of colonoscopy in screening for colorectal cancer.  Ann Intern Med. 2000;  133 573-584
  • 51 U. S. Department of Labor. Bureau of Labor Statistics. .Consumer price index for all urban consumers (CPI-U), U. S. city average, medical care. http://Available at: www.bls.gov/cpi/home.htm. Accessed April 14, 2007
  • 52 National compensation survey: occupational wages in the United States, June 2005. Available from URL: http://www.bls.gov. Accessed 14 April 14 2007
  • 53 Heitman S J, Manns B J, Hilsden R J. et al . Cost-effectiveness of computerized tomographic colonography versus colonoscopy for colorectal cancer screening.  CMAJ. 2005;  173 877-881
  • 54 Tengs T O, Wallace A. One thousand health-related quality-of-life estimates.  Med Care. 2000;  38 583-637
  • 55 Janz N K, Wren P A, Schottenfeld D. et al . Colorectal cancer screening attitudes and behavior: a population-based study.  Prev Med. 2003;  37 627-634
  • 56 Seeff L C, Shapiro J A, Nadel M R. Are we doing enough to screen for colorectal cancer? Findings from the 1999 Behavioral Risk Factor Surveillance System.  J Fam Pract. 2002;  51 761-766
  • 57 Barclay R L, Vicari J J, Doughty A S. et al . Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.  N Engl J Med. 2006;  355 2533-2541
  • 58 van Dam J, Cotton P, Johnson C D. et al . AGA future trends report: CT colonography.  Gastroenterology. 2004;  127 970-984
  • 59 Cotton P B, Durkalski V L, Pineau B C. et al . Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia.  JAMA. 2004;  291 1713-1719
  • 60 Atkin W, Rogers P, Cardwell C. et al . Wide variation in adenoma detection rates at screening flexible sigmoidoscopy.  Gastroenterology. 2004;  126 1247-1256

C. Hassan, MD

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Gastroenterologia ed Endoscopia Digestiva

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