Surveillance Colonoscopy Is Cost-Effective for Patients With Adenomas Who Are at High Risk of Colorectal Cancer

Background & Aims

Guidelines recommend that patients with colon adenomas undergo periodic surveillance colonoscopy. The purpose of this study was to estimate the cost-effectiveness of these recommendations.

Methods

We developed a Markov model to study various surveillance strategies from the perspective of a long-term payer. We modeled a cohort of 50-year-old patients with newly diagnosed adenomas, following them until death. Thirty percent of the population was assumed to be at high risk for colorectal cancer. Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were measured.

Results

Performing colonoscopies every 3 years in high-risk patients and every 10 years in low-risk patients (3/10 strategy) was more costly but also more effective than no surveillance, with an ICER of $5743 per QALY gained. Compared with this 3/10 strategy, a 3/5 strategy was considerably more costly but only marginally more effective, with an ICER of $296266 per QALY. A 3/3 strategy was more costly and less effective than a 3/5 strategy (dominated). Results were most sensitive to the annual probability of advanced adenoma formation and the relative risk (RR) of advanced adenoma formation in high-risk versus low-risk patients. Assuming that the probability of advanced adenoma formation was 1.3% per year (base: 0.5%), the ICER of the 3/5 strategy was <$50000 per QALY gained if the RR of advanced adenoma formation was <2.4 (base: 3.9).

Conclusions

Surveillance colonoscopy is cost-effective for patients who are at high risk for developing colorectal cancer. Aggressive surveillance can be expensive or even harmful; efforts should be made to improve risk models for colonic neoplasia.

Keywords: Cost-Utility Analysis, Cancer Screening, Risk Stratification, Overuse

Abbreviations used in this paper: CRC, colorectal cancer, ICER, incremental cost-effectiveness ratio, NHB, net health benefit, NPS, National Polyp Study, QALY, quality-adjusted life-year, RR, relative risk, SEER, Surveillance, Epidemiology, and End Results, USD, US dollars, WTP, willingness-to-pay