Title: Evaluating options for a colorectal cancer screening programme in Ireland
1Evaluating options for a colorectal cancer
screening programme in Ireland
- Sharp L, Tilson L, Whyte S, Ó Céilleachair A,
Walsh C, Usher C, Tappenden P, Chilcott J,
Staines A, Barry M Comber H.
Population-based cancer research in Ireland,
Davenport Hotel September 4th 2009
2Background
- Over 2,000 new cases of colorectal cancer (CRC)
are diagnosed in the Republic of Ireland each
year. - 2nd most common cancer for both genders
- Over 900 deaths per annum from CRC
- On most key indicators Irish people fare worse
than their European contemporaries - Higher incidence rates
- Lower survival rates
- Higher mortality amongst men
- As population ages incidence is projected to
increase
3Opportunity for Screening
- If caught early, CRC is very treatable
- Survival much higher in Stage I-II disease
- Screening in place for many European countries
- Numerous modalities exist for early detection of
CRC - Guaic-based occult blood tests (gFOBT)
- Immunochemical-based stool tests (FIT)
- Flexible sigmoidoscopy
4Cost-effectiveness analysis
- Comparing the cost-effectiveness of two policies,
A and B - ICER cost A cost B/effect A effect B
- Effects may be in life-years gained (LYG) or
quality-adjusted life years gained (QALYs) - The lower the ICER the more cost-effective A
compared to B - 45,000 per QALY is an informal threshold of
cost-effectiveness in an Irish setting
5Evaluating Screening Options
- Health technology assessment commissioned by HIQA
- Evaluate using cost-effectiveness analysis
competing alternative strategies for CRC
screening in Ireland - Versus No Screening and also incrementally
against each other - Estimate the likely resource burden of screening
for a range of key services and also health
outcomes over a ten year time horizon after the
introduction of screening.
6Methods
- Core screening scenarios agreed with HIQA Expert
Advisory Group - biennial FIT at ages 55-74
- biennial gFOBT at ages 55-74, with reflex FIT
- FSIG once only at age 60
- Supplementary scenarios also considered
- Diagnostic investigations for postive screen
test colonoscopy or CT colonography - Surveillance for those with adenoma(s) 1cm
removed following current consensus
recommendations (Atkins Saunders, 2002)
7Model
- Markov model adapted from an existing model
developed by collaborators in ScHARR - Natural history model of CRC
- Hypothetical cohort of 55 year-olds tracked over
their lifetime used for cost-effectiveness - Screening scenarios were then superimposed on
this model - Outcome measures Cost per QALY and cost per Life
Year Gained (LYG) - Alternatives compared to No Screening and each
other - Costs and outcomes discounted _at_ 4
- Healthcare payer perspective
8Data
- Model parameters
- Natural history data
- Data on the performance of tests
- Cost data
- Other data such as uptake
- Data sourced from extensive literature reviews,
information from existing screening programmes
and expert opinion - Sensitivity analysis
- One/multi way
- Probabilistic sensitivity analysis
9Performance and Uptake
10Costs
11Incremental Cost Effectiveness vs. No Screening
Costs and outcomes discounted at 4 1 Each
incremental value compares value for that
strategy to common baseline of no screening 2
gFOBT considered dominated by a combination of
FIT and FSIG
12Cost-Effectiveness Plane
13CE Plane Extended Dominance
14Health Outcomes
15Health Outcomes
- Higher proportion of screen-detected with FIT
(30 of all cancers, vs 14 with gFOBT and 3
with FSIG) - Under all scenarios, screen-detected cancers have
more favourable stage distribution than those
detected symptomatically/clinically - Sensitivity analysis found analysis to be robust.
Findings did not change when using LYG as outcome
measure
16FSIG v FIT
17But
FITfaecal immunochemical test FSIG flexible
sigmoidoscopy gFOBTguaiac-based faecal occult
blood test 1 Over the entire lifetime of the
cohort, therefore for gFOBT and FIT includes 10
screening rounds 2 Related to screening,
diagnosis or surveillance 3 Complications
associated with diagnostic and surveillance
colonoscopy and, where relevant, FSIG 4 Major
abdominal bleeding, requiring admission or
intervention
18Conclusions
- Compared to No Screening all of the options
considered could be termed highly cost-effective. - Biennial FIT 55-74 optimal strategy as it
provides greater health gains at an acceptable
ICER - Not insignificant resource considerations and
complications need to be borne in mind
19Thank You