Treating colon cancer is expensive, with a recent study estimating the cost 1 year after diagnosis at $29,196 in a cohort of Medicare colon cancer patients aged 66 years and older.1 Reducing colorectal cancer (CRC) incidence through screening could restrain these expenditures, and several recent studies have pointed out screening’s benefits. A 2006 study looked at whether changes in Medicare’s reimbursement policy to provide for coverage of screening colonoscopies for patients with increased risk for colon cancer (in 1998) and then for all individuals (in 2001) led to an increase in colonoscopy use or early-stage colon cancer diagnosis.2 Colonoscopy use increased from an average of 285 of 100,000 before the policy change to 1919 of 100,000 after the change. The changes were also strongly associated with cancer being diagnosed at an early stage.
Rabeneck and colleagues conducted a naturalistic, 14-year follow-up of Canadian men and women aged 50 to 90 years who underwent varying intensities of colonoscopy.3 Col onoscopy increased in all regions during 1993- 2006, and among this cohort of 2,412,077 persons, the authors found that for each 1% increase in colonoscopy rates, there was a concomitant 3% decrease in colon cancer deaths.
Cost-Effectiveness of Screening Emerging Because of the number of screening tests available, studies have also begun to examine the cost-effectiveness of individual screening methods. Another Canadian study modeled the costs and quality-adjusted life expectancy of not screening and screening with any of 10 tests.4 The authors found that an annual high-sensitivity fecal occult blood test (FOBT), such as a fecal immunochemical test, or colon oscopy every 10 years, offered the best value.
The Centers for Medicare & Medicaid Services (CMS) has begun to commission cost-effectiveness studies of CRC screening approaches. Cur rently, Medicare covers the following screening tests: annual FOBT; flexible sigmoidoscopy every 5 years (both alone and in conjunction with annual FOBT), and colonoscopy every 10 years. One study evaluated the conditions under which stool DNA testing could be cost-effective compared with these currently reimbursed tests.5 Using microsimulation modeling, the authors looked at lifetime expectancy, lifetime costs, incremental cost-effectiveness ratios, and threshold costs in a population aged 65 years. At a cost of $350 per test, testing every 3 or 5 years yielded fewer lifeyears and higher costs than the current recommended screening strategies. The authors conclude that there is no way for the test to be cost-effective at this rate; the journal’s editors suggest that “stool DNA testing will not be a costeffective screening test for the foreseeable future.”
Computed tomographic colonography (CTC) has emerged as another option in colon cancer screening, but the test is also relatively costly and the CMS has decided not to cover the procedure. The authors of the previous study also explored what the reimbursement rate for CTC would have to be for this procedure to be cost-effective relative to other screening methods (and for the CMS to cover it).6 The simulation models used in the paper found that although the number of undiscounted life-years gained from CTC screening was comparable to 5- yearly sigmoidoscopy with annual FOBT, the strategy was the most costly one when it was reimbursed at a perscan rate of $488 (slightly less than the reimbursement for colonoscopy without polypectomy). The strategy could be cost-effective, however, when reimbursed at $108 to $205 per scan.
Cost-Benefits and Harms An editorial accompanying this second study, by Russell Harris, MD, MPH, of the University of North Carolina School of Medicine, cautions of the dangers associated with both CTC and optical colonoscopy and wonders if there might be a third option.7 In terms of cost-effectiveness, an im proved fecal test could well be the new “gold standard,” he writes. But in a follow-up interview with Value-Based Cancer Care, Dr Harris explained that “net effectiveness,” which considers costs and benefits minus harms, might be an additional, helpful way of considering cost-effectiveness.
“What you want with a colorectal cancer screening test is one that’s less sensitive than colonoscopy,” so that clinically unimportant findings are not acted on, Dr Harris said. “Where colonoscopy is going too far, we need to back up a bit and find some test that is better suited to what we’re looking for.”
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