title: Cost-effectiveness of colorectal cancer screening in Germany: current endoscopic and fecal testing strategies versus plasma methylated Septin 9 DNA.
abstract: OBJECTIVE
  Colorectal cancer (CRC) screening strategies in Germany include guaiac-based fecal occult blood testing (gFOBT) starting at age 50 and a switch to colonoscopy at age 55 or continued gFOBT testing, but screening utilization is limited. Blood-based biomarkers, such as methylated Septin 9 DNA ( (m) SEPT9), may improve screening rates. We performed a cost-effectiveness analysis of current and emerging CRC screening strategies in Germany.
  
  
  METHODS
  Using a validated Markov model, we compared annual gFOBT for ages 50 through 54 followed by biennial testing until age 75 (FOBT) or by colonoscopy at ages 55 and 65 (FOBT/COLO 55,65), substitution of fecal immunochemical testing (FIT) for gFOBT (FIT, FIT/COLO 55,65), and annual or biennial plasma (m) SEPT9 testing. We also considered persons who utilize only colonoscopy and varied age at colonoscopy utilization.
  
  
  RESULTS
  The current strategies were more effective and less costly than no screening. FIT was more effective and less costly than (m) SEPT9 testing. FIT/COLO 55,65 cost €12 200 per quality-adjusted life-years gained in comparison with FIT. (m) SEPT9-based screening was cost-effective in comparison with no screening but was dominated by other cost-saving strategies. Differential screening utilization and adherence greatly affected incremental results between strategies. In probabilistic analyses, FIT was preferred in 49 % and FIT/COLO 55,65 in 47 % of iterations.
  
  
  CONCLUSIONS
  Currently available CRC screening strategies in Germany, including hybrid fecal testing/colonoscopy, are likely to be cost-saving. Current strategies appear superior to (m) SEPT9-based screening. The impact of blood-based biomarkers is likely to depend on utilization and adherence as much as on test performance characteristics and cost.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Uri
authors.initials: U
authors.lastname: Ladabaum
authors.affiliation: Boston Healthcare Associates International GmbH, Berlin, Germany.
authors.forename: Lourdes
authors.initials: L
authors.lastname: Alvarez-Osorio
authors.affiliation: Charité Medical University of Berlin, Virchow Clinic Campus, Berlin, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Rösch
authors.affiliation: Boston Healthcare Associates International GmbH, Berlin, Germany ; Steinbeis University, Berlin, Germany.
authors.forename: Bernd
authors.initials: B
authors.lastname: Brueggenjuergen