Background/Aims: There is increasing discussion regarding screening strategies for colorectal cancer (CRC). Recent evidence suggests guidelines should be individualized by age and race to minimize disease burden and screening costs. The United States Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer (A recommendation). The USPSTF evidence review found good, direct evidence of the effectiveness of fecal occult blood testing (FOBT); fair, direct evidence for the effectiveness of flexible sigmoidoscopy; and indirect evidence for combined FOBT & flexible sigmoidoscopy, colonoscopy alone, and double contrast barium enema.
Methods: A 9-state discreet-time Markov micro simulation of the natural progression of colorectal cancer estimated CRC incidence and treatment costs for a US birth cohort. Specific emphasis was given to known differences in incidence and progression among men, women, blacks, and whites. We compared the natural history “base case” of no screening to three alternative strategies: 1) Screening at age 50 with variable screening technologies, 2) 10-year colonoscopy starting at age 50, 3) 10-year colonoscopy with starting age individualized to gender and race.
Results: The base case scenario had an overall burden of 5,712 cases and 2,027 deaths per 100,000 with the highest burden being among black makes (6,118 cases and 2,430 deaths). The current USPSTF recommendation would save 5,082 QALYs 100,000 for a CE ratio of $22,358 with the largest impact being among black males (7000 QALYs/100,000; CE ratio of $20,236). Starting at age 50, 10-year colonoscopies would save 6,132 QALYs/100,000 (CE ratio of $40,912). A tailored strategy which would begin screening black males at age 40, black females at age 45, white males at age 50 and white females at age 55 would save 7,509 QALYs/100,000 (CE ratio of $15,567).
Conclusions: Individualized guidelines for CRC screening could contribute to decreasing disparities in disease burden between blacks and whites in a cost effective manner. The acceptability of such guidelines should be explored.