A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening.
OBJECTIVE
A "resect and discard" policy has been proposed for diminutive polyps detected by screening colonoscopy, because hyperplastic and adenomatous polyps can be distinguished, in vivo, by using narrow-band imaging (NBI). We modeled the cost-effectiveness of this policy.


METHODS
Markov modeling was used to compare the cost-effectiveness of universal pathology evaluations with a resect and discard policy for colonoscopy screening. In a resect and discard approach, diminutive lesions (≤5 mm), classified by endoscopy with high confidence, were not analyzed by a pathologist. Base case assumptions of an 84% rate of high-confidence classification, with a sensitivity and specificity for adenomas of 94% and 89%, respectively, were used. Census data were used to project outputs of the model onto the US population, assuming 23% as the current rate of adherence to a colonoscopy screening.


RESULTS
With universal referral of resected polyps to pathology, colonoscopy screening costs an estimated $3222/person, with a gain of 51 days/person. Endoscopic polypectomy accounted for $179/person, of which $46/person was related to pathology examination. Adoption of a resect and discard policy for eligible diminutive polyps resulted in a savings of $25/person, without any meaningful effect on screening efficacy. Projected onto the US population, this approach would result in an undiscounted annual savings of $33 million. In the sensitivity analysis, the rate of high-confidence diagnosis and the accuracy for endoscopic polyp determination were the most meaningful variables.


CONCLUSIONS
In a simulation model, a resect and discard strategy for diminutive polyps detected by screening colonoscopy resulted in a substantial economic benefit without an impact on efficacy.
Hassan
Cesare
C
Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy. cesareh@hotmail.com
Pickhardt
Perry J
PJ
Rex
Douglas K
DK
D000368:Aged; D000369:Aged, 80 and over; D003111:Colonic Polyps / Q000175:diagnosis* / Q000601:surgery; D003113:Colonoscopy / Q000191:economics* / Q000379:methods*; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000601:surgery; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics* / Q000379:methods*; D006651:Histocytochemistry / Q000191:economics / Q000379:methods; D006801:Humans; D008875:Middle Aged; D015233:Models, Statistical; D014481:United States