Computed tomographic colonography to screen for colorectal cancer, extracolonic cancer, and aortic aneurysm: model simulation with cost-effectiveness analysis.
BACKGROUND
In addition to detecting colorectal neoplasia, abdominal computed tomography (CT) with colonography technique (CTC) can also detect unsuspected extracolonic cancers and abdominal aortic aneurysms (AAA).The efficacy and cost-effectiveness of this combined abdominal CT screening strategy are unknown.


METHODS
A computerized Markov model was constructed to simulate the occurrence of colorectal neoplasia, extracolonic malignant neoplasm, and AAA in a hypothetical cohort of 100,000 subjects from the United States who were 50 years of age. Simulated screening with CTC, using a 6-mm polyp size threshold for reporting, was compared with a competing model of optical colonoscopy (OC), both without and with abdominal ultrasonography for AAA detection (OC-US strategy).


RESULTS
In the simulated population, CTC was the dominant screening strategy, gaining an additional 1458 and 462 life-years compared with the OC and OC-US strategies and being less costly, with a savings of $266 and $449 per person, respectively. The additional gains for CTC were largely due to a decrease in AAA-related deaths, whereas the modeled benefit from extracolonic cancer downstaging was a relatively minor factor. At sensitivity analysis, OC-US became more cost-effective only when the CTC sensitivity for large polyps dropped to 61% or when broad variations of costs were simulated, such as an increase in CTC cost from $814 to $1300 or a decrease in OC cost from $1100 to $500. With the OC-US approach, suboptimal compliance had a strong negative influence on efficacy and cost-effectiveness. The estimated mortality from CT-induced cancer was less than estimated colonoscopy-related mortality (8 vs 22 deaths), both of which were minor compared with the positive benefit from screening.


CONCLUSIONS
When detection of extracolonic findings such as AAA and extracolonic cancer are considered in addition to colorectal neoplasia in our model simulation, CT colonography is a dominant screening strategy (ie, more clinically effective and more cost-effective) over both colonoscopy and colonoscopy with 1-time ultrasonography.
Hassan
Cesare
C
Gastroenterology and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, and Department of Radiological Sciences, University Polo Pontino, Rome, Italy. cesareh@hotmail.com
Pickhardt
Perry J
PJ
Pickhardt
Perry
P
Laghi
Andrea
A
Kim
Daniel H
DH
Kim
Daniel
D
Zullo
Angelo
A
Iafrate
Franco
F
Di Giulio
Lorenzo
L
Morini
Sergio
S
D000008:Abdominal Neoplasms / Q000000981:diagnostic imaging*; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging*; D023881:Colonography, Computed Tomographic / Q000191:economics; D015179:Colorectal Neoplasms / Q000000981:diagnostic imaging*; D003362:Cost-Benefit Analysis; D004526:Efficiency; D008390:Markov Chains; D008962:Models, Theoretical; D009010:Monte Carlo Method; D010349:Patient Compliance; D012680:Sensitivity and Specificity; D014463:Ultrasonography