Estimation of Benefits, Burden, and Harms of Colorectal Cancer Screening Strategies: Modeling Study for the US Preventive Services Task Force.
OBJECTIVE
The US Preventive Services Task Force (USPSTF) is updating its 2008 colorectal cancer (CRC) screening recommendations.


OBJECTIVE
To inform the USPSTF by modeling the benefits, burden, and harms of CRC screening strategies; estimating the optimal ages to begin and end screening; and identifying a set of model-recommendable strategies that provide similar life-years gained (LYG) and a comparable balance between LYG and screening burden.


METHODS
Comparative modeling with 3 microsimulation models of a hypothetical cohort of previously unscreened US 40-year-olds with no prior CRC diagnosis.


METHODS
Screening with sensitive guaiac-based fecal occult blood testing, fecal immunochemical testing (FIT), multitarget stool DNA testing, flexible sigmoidoscopy with or without stool testing, computed tomographic colonography (CTC), or colonoscopy starting at age 45, 50, or 55 years and ending at age 75, 80, or 85 years. Screening intervals varied by modality. Full adherence for all strategies was assumed.


METHODS
Life-years gained compared with no screening (benefit), lifetime number of colonoscopies required (burden), lifetime number of colonoscopy complications (harms), and ratios of incremental burden and benefit (efficiency ratios) per 1000 40-year-olds.


RESULTS
The screening strategies provided LYG in the range of 152 to 313 per 1000 40-year-olds. Lifetime colonoscopy burden per 1000 persons ranged from fewer than 900 (FIT every 3 years from ages 55-75 years) to more than 7500 (colonoscopy screening every 5 years from ages 45-85 years). Harm from screening was at most 23 complications per 1000 persons screened. Strategies with screening beginning at age 50 years generally provided more LYG as well as more additional LYG per additional colonoscopy than strategies with screening beginning at age 55 years. There were limited empirical data to support a start age of 45 years. For persons adequately screened up to age 75 years, additional screening yielded small increases in LYG relative to the increase in colonoscopy burden. With screening from ages 50 to 75 years, 4 strategies yielded a comparable balance of screening burden and similar LYG (median LYG per 1000 across the models): colonoscopy every 10 years (270 LYG); sigmoidoscopy every 10 years with annual FIT (256 LYG); CTC every 5 years (248 LYG); and annual FIT (244 LYG).


CONCLUSIONS
In this microsimulation modeling study of a previously unscreened population undergoing CRC screening that assumed 100% adherence, the strategies of colonoscopy every 10 years, annual FIT, sigmoidoscopy every 10 years with annual FIT, and CTC every 5 years performed from ages 50 through 75 years provided similar LYG and a comparable balance of benefit and screening burden.
Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
Amy B
AB
Knudsen
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
Ann G
AG
Zauber
RAND Corporation, Santa Monica, California.
Carolyn M
CM
Rutter
Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands.
Steffie K
SK
Naber
Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland.
V Paul
VP
Doria-Rose
Group Health Research Institute, Seattle, Washington.
Chester
C
Pabiniak
Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts8Currently with Optum, Boston, Massachusetts.
Colden
C
Johanson
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
Sara E
SE
Fischer
Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands.
Iris
I
Lansdorp-Vogelaar
Department of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis.
Karen M
KM
Kuntz
D000236:Adenoma / Q000175:diagnosis; D000328:Adult; D026683:Advisory Committees; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D023881:Colonography, Computed Tomographic; D003113:Colonoscopy / Q000009:adverse effects / Q000706:statistics & numerical data; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D004247:DNA / Q000032:analysis; D055088:Early Detection of Cancer / Q000379:methods; D005243:Feces / Q000737:chemistry; D006801:Humans; D007150:Immunohistochemistry; D008875:Middle Aged; D008962:Models, Theoretical; D009780:Occult Blood; D011314:Preventive Health Services; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity; D012812:Sigmoidoscopy; D013997:Time Factors; D014481:United States
D004247:DNA