title: Comparing the effectiveness of competing tests for reducing colorectal cancer mortality: a network meta-analysis.
abstract: BACKGROUND
  Comparative effectiveness data pertaining to competing colorectal cancer (CRC) screening tests do not exist but are necessary to guide clinical decision making and policy.
  
  
  OBJECTIVE
  To perform a comparative synthesis of clinical outcomes studies evaluating the effects of competing tests on CRC-related mortality.
  
  
  METHODS
  Traditional and network meta-analyses. Two reviewers identified studies evaluating the effect of guaiac-based fecal occult blood testing (gFOBT), flexible sigmoidoscopy (FS), or colonoscopy on CRC-related mortality.
  
  
  METHODS
  gFOBT, FS, colonoscopy.
  
  
  METHODS
  Traditional meta-analysis was performed to produce pooled estimates of the effect of each modality on CRC mortality. Bayesian network meta-analysis (NMA) was performed to indirectly compare the effectiveness of screening modalities. Multiple sensitivity analyses were performed.
  
  
  RESULTS
  Traditional meta-analysis revealed that, compared with no intervention, colonoscopy reduced CRC-related mortality by 57% (relative risk [RR] 0.43; 95% confidence interval [CI], 0.33-0.58), whereas FS reduced CRC-related mortality by 40% (RR 0.60; 95% CI, 0.45-0.78), and gFOBT reduced CRC-related mortality by 18% (RR 0.82; 95% CI, 0.76-0.88). NMA demonstrated nonsignificant trends favoring colonoscopy over FS (RR 0.71; 95% CI, 0.45-1.11) and FS over gFOBT (RR 0.74; 95% CI, 0.51-1.09) for reducing CRC-related deaths. NMA-based simulations, however, revealed that colonoscopy has a 94% probability of being the most effective test for reducing CRC mortality and a 99% probability of being most effective when the analysis is restricted to screening studies.
  
  
  CONCLUSIONS
  Randomized trials and observational studies were combined within the same analysis.
  
  
  CONCLUSIONS
  Clinical outcomes studies demonstrate that gFOBT, FS, and colonoscopy are all effective in reducing CRC-related mortality. Network meta-analysis suggests that colonoscopy is the most effective test.
authors.affiliation: Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan, USA.
authors.forename: B Joseph
authors.initials: BJ
authors.lastname: Elmunzer
authors.affiliation: Department of Internal Medicine, Division of Digestive and Liver Diseases and the Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Amit G
authors.initials: AG
authors.lastname: Singal
authors.affiliation: Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA.
authors.forename: Jeremy B
authors.initials: JB
authors.lastname: Sussman
authors.affiliation: Department of Internal Medicine, Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, USA.
authors.forename: Amar R
authors.initials: AR
authors.lastname: Deshpande
authors.affiliation: Department of Internal Medicine, Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, USA.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Sussman
authors.affiliation: University of Michigan School of Medicine, Ann Arbor, Michigan, USA.
authors.forename: Marisa L
authors.initials: ML
authors.lastname: Conte
authors.affiliation: Department of Radiology, Division of Nuclear Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA.
authors.forename: Ben A
authors.initials: BA
authors.lastname: Dwamena
authors.affiliation: Department of Internal Medicine, Division of General Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA.
authors.forename: Mary A M
authors.initials: MA
authors.lastname: Rogers
authors.affiliation: Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan, USA; Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan, USA.
authors.forename: Philip S
authors.initials: PS
authors.lastname: Schoenfeld
authors.affiliation: Department of Medicine, Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Inadomi
authors.affiliation: Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan, USA; Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan, USA.
authors.forename: Sameer D
authors.initials: SD
authors.lastname: Saini
authors.affiliation: Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan, USA; Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan, USA.
authors.forename: Akbar K
authors.initials: AK
authors.lastname: Waljee
mesh_terms: D001499:Bayes Theorem; D003113:Colonoscopy / Q000379:methods*; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000401:mortality*; D057186:Comparative Effectiveness Research; D055088:Early Detection of Cancer / Q000379:methods*; D006801:Humans; D009780:Occult Blood; D012812:Sigmoidoscopy