There is already clear evidence that colorectal cancer screening is cost effective in saving lives. A modeling study by Lansdorp-Vogelaar and colleagues from the Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands recently published in the Journal of the National Cancer Institute (2009;101:1412–1422) now predicts that some colorectal screening tests may provide a net savings by reducing a later need for expensive treatment.

The microsimulation study modeled the costs of 6 screening and 3 treatment scenarios in a theoretical population that is representative of the US population. The screening scenarios included 5 options recommended by both the American Cancer Society/US Multisociety Taskforce/American College of Radiology 2008 guidelines and by the US Preventive Services Taskforce. Options include fecal occult-blood testing (FOBT) with Hemoccult II (Beckman Coulter, Fullerton, California), immunochemical FOBT, flexible sigmoidoscopy, flexible sigmoidoscopy plus FOBT, and colonoscopy, as well as no screening. (Three other options from the American Cancer Society/US Multisociety Taskforce/American College of Radiology guidelines, computed tomography [CT] colonography [also known as virtual colonoscopy], double contrast barium enema, and stool DNA testing, were not considered).

The analysis also included cost estimates for past, present, and near-future treatment regimens at stages I-IV and for terminal disease. Resulting from the addition of new drugs such as irinotecan, oxaliplatin, and bevacizumab, the clear trend was one of substantially increasing costs over time for treating late stage and terminal disease.

CRC Screening Saves Money

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  2. CRC Screening Saves Money
  3. Cost Saving Takes Time

The result of this analysis was that screening with all options except colonoscopy provided a net savings when treatment included newer and more expensive drugs. In the present treatment scenario, colonoscopy was already highly cost effective in terms of the usual standards of dollars per year of life saved. Colonoscopy's cost effectiveness was even better for models based on near-future treatment assumptions, although it still had a small net cost. The researchers pointed out that colonoscopy is more costly than other screening methods and that its main advantage over other tests is additional prevention of early stage disease, for which treatment is less expensive.

“Our study shows that the treatment savings from screening will be larger than screening costs in the near future when the new chemotherapy regimens become general practice. This reflects the higher costs per life-year saved of these new treatments compared with screening,” says first author Iris Lansdorp-Vogelaar, PhD, in an e-mail interview with CA: A Cancer Journal for Clinicians.

“If screening becomes cost saving, it can play an important role in containing the increasing costs for the treatment of colorectal cancer,” says Lansdorp-Vogelaar.

Using the microsimulation model, Lansdorp-Vogelaar and colleagues found that “compared with no screening, the treatment savings from preventing advanced colorectal cancer and colorectal cancer deaths by screening more than doubled with the widespread use of new chemotherapies.”

“The advantage to this study is that it was not just a cost-effectiveness model alone: this is an entire disease model. The accuracy and validity of these results are probably better than other, similar studies,” says Richard Wender, MD, alumni professor and chair of the Department of Family and Community Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania. “We have known for some time that screening for colon cancer constitutes good public health. Proving that it is a sound economic investment can help us overcome one barrier to universal screening,” he adds.

Cost Saving Takes Time

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  2. CRC Screening Saves Money
  3. Cost Saving Takes Time

Lansdorp-Vogelaar and colleagues also point out the chronology of cost savings in their article. “It takes 25 to 40 years after the start of a screening strategy before the treatment savings of that strategy outweigh its costs,” they write. “If insurers anticipate that beneficiaries will not stay in their program for more than 5 years, they may be less inclined to cover a colorectal cancer screening program despite long-term savings of such a program.” They also note that in the United States, most of the screening costs would be paid by private insurance and that Medicare would reap most of the benefit from less treatment.

“I think that the people who conducted the study believe, as I do, that it is in the public health interest to undergo screening, and that they are frustrated, as I am, by the shortsightedness of payers,” says Leonard Saltz, MD, professor of medicine at Weill Cornell Medical College and attending physician at the Memorial Sloan-Kettering Cancer Center, both in New York City. “But I don't think their findings are going to change the opinions of payers. The idea to a third-party payer of ‘I will save money… 20 years down the road’ is not going to fit into the [current US insurance] business model,” he says.

Dr. Wender says most payers have already figured out that the public expects to be supported in their personal efforts to prevent cancer. “But ultimately, the public will have to stand up and clearly state, through their votes and advocacy efforts, what value they expect to receive for their healthcare dollar,” he says. 1

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Illustration 1. A fecal occult-blood test card is shown.

Credit: Beckman Coulter, Inc.

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