Colonoscopy appears to be the best strategy for colorectal cancer screening

NEW YORK (Reuters Health) – Colonoscopies performed at ages 50 and 60 years may be the most effective and most cost-effective screening test for colorectal cancer, researchers suggest.

Dr. Sandeep Vijan, of Veterans Health Services Research and Development in Ann Arbor, Michigan, and colleagues constructed a Markov cost-effectiveness model using data from colonoscopic screening studies, autopsy studies, the Surveillance, Epidemiology and End Results registry, and the National Center for Health Statistics.

They note that recent research suggests that at least 75% of cancers arise from polyps. Randomized trials have shown rates of compliance with screening range from 50% to 75%.

Costs were approached from the perspective of third-party payers. As the researchers report in The American Journal of Medicine for December 1, 2001, compared with no screening, the cost-effectiveness ratio for all screening strategies is less than $20,000 per life-year gained, regardless of compliance levels.

If compliance were 100%, annual fecal occult blood testing beginning at age 50, combined with flexible sigmoidoscopy, would be more effective, but also more costly than twice-lifetime colonoscopy. Decreasing compliance causes non-colonoscopic strategies to become more costly and less effective, they report

The combination flexible sigmoidoscopy and fecal occult blood testing approach is the best strategy only when 50% of cancers arise from polyps, compliance is 75% or greater, and costs are moderate. It is also the preferred strategy when "50% of cancers arise from polyps, compliance is 50%, and the cost of colonoscopy is $1000 or more," the authors write.

Editorialist Dr. Joe V. Selby, of Kaiser Permanente Northern California in Oakland, takes exception to the findings of Dr. Vijan's group. He suggests that patients may find twice-lifetime colonoscopy a less acceptable strategy because of the increased discomfort of the bowel preparation required and the intravenous sedation used. In addition, he claims the researchers' cost-effectiveness analysis failed to account for start-up costs.

Perhaps the biggest obstacles, he maintains, are related to the number of highly trained personnel required to perform the increased number of colonoscopies.

Dr. Selby concludes that physicians continue to follow the recommendations of the American Cancer Society, in which decisions regarding screening methods are based on patient preference and availability of screening resources.

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