title: Cost effectiveness and projected national impact of colorectal cancer screening in France.
abstract: BACKGROUND
  Colorectal cancer (CRC) is a major cause of morbidity and mortality in France. Only scanty data on cost-effectiveness of CRC screening in Europe are available, generating uncertainty over its efficiency. Although immunochemical fecal tests (FIT) and guaiac-based fecal occult blood tests (g-FOBT) have been shown to be cost-effective in France, cost-effectiveness of endoscopic screening has not yet been addressed.
  
  
  METHODS
  Cost-effectiveness of screening strategies using colonoscopy, flexible sigmoidoscopy, second-generation colon capsule endoscopy (CCE), FIT and g-FOBT were compared using a Markov model. A 40 % adherence rate was assumed for all strategies. Colonoscopy costs included anesthesiologist assistance. Incremental cost-effectiveness ratios (ICERs) were calculated. Probabilistic and value-of-information analyses were used to estimate the expected benefit of future research. A third-payer perspective was adopted.
  
  
  RESULTS
  In the reference case analysis, FIT repeated every year was the most cost-effective strategy, with an ICER of €48165 per life-year gained vs. FIT every 2 years, which was the next most cost-effective strategy. Although CCE every 5 years was as effective as FIT 1-year, it was not a cost-effective alternative. Colonoscopy repeated every 10 years was substantially more costly, and slightly less effective than FIT 1-year. When projecting the model outputs onto the French population, the least (g-FOBT 2-years) and most (FIT 1-year) effective strategies reduced the absolute number of annual CRC deaths from 16037 to 12916 and 11217, respectively, resulting in an annual additional cost of €26 million and €347 million, respectively. Probabilistic sensitivity analysis demonstrated that FIT 1-year was the optimal choice in 20% of the simulated scenarios, whereas sigmoidoscopy 5-years, colonoscopy, and FIT 2-years were the optimal choices in 40%, 26%, and 14%, respectively.
  
  
  CONCLUSIONS
  A screening program based on FIT 1-year appeared to be the most cost-effective approach for CRC screening in France. However, a substantial uncertainty over this choice is still present.
authors.affiliation: Digestive Endoscopy Unit, Catholic University, Rome, Italy. cesareh@hotmail.com
authors.forename: C
authors.initials: C
authors.lastname: Hassan
authors.forename: R
authors.initials: R
authors.lastname: Benamouzig
authors.forename: C
authors.initials: C
authors.lastname: Spada
authors.forename: T
authors.initials: T
authors.lastname: Ponchon
authors.forename: A
authors.initials: A
authors.lastname: Zullo
authors.forename: J C
authors.initials: JC
authors.lastname: Saurin
authors.forename: G
authors.initials: G
authors.lastname: Costamagna
mesh_terms: D053704:Capsule Endoscopy / Q000191:economics*; D003113:Colonoscopy / Q000191:economics*; D015179:Colorectal Neoplasms / Q000517:prevention & control*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D005602:France; D006801:Humans; D008390:Markov Chains; D008403:Mass Screening / Q000191:economics*; D009780:Occult Blood; D012812:Sigmoidoscopy / Q000191:economics*