CTC to Screen for Colorectal Cancer and Aortic Aneurysm in Medicare Population
CTC to Screen for Colorectal Cancer and Aortic Aneurysm in Medicare Population
Objective. CT colonography (CTC) is a recommended test for colorectal cancer (CRC) screening according to the updated 2008 American Cancer Society guidelines. CTC can also accurately detect abdominal aortic aneurysm (AAA). This collaborative gastroenterology–radiology project evaluated the cost-effectiveness and clinical efficacy of CTC in the Medicare population.
Materials and Methods. A computerized Markov model simulated the development of CRC and AAA in a hypothetical cohort of 100,000 U.S. adults ≥65 years old. Screening with CTC at 5- and 10-year intervals using a 6-mm size threshold for polypectomy was compared with primary optical colonoscopy screening every 10 years and with no screening. Base case costs for CTC and optical colonoscopy were $674 and $795, respectively. The costs of the imaging workup for extracolonic findings at CTC were also included.
Results. CTC resulted in 7,786 and 7,027 life-years gained at 5- and 10-year intervals, respectively, compared with 6,032 life-years gained with 10-year optical colonoscopy. The increase in overall efficacy with CTC was primarily due to prevention of AAA rupture because CRC prevention and CRC detection rates were similar for CTC and optical colonoscopy. All three strategies were highly cost-effective compared with no screening, with an incremental cost-effectiveness ratio (ICER) of $6,088, $1,251, and $1,104 per life-year gained for 5-year CTC, 10-year CTC, and 10-year optical colonoscopy strategies, respectively. The ICER of 5-year CTC and 10-year CTC versus optical colonoscopy was $23,234 and $2,144 per life-year gained, respectively.
Conclusion. Because of its ability to simultaneously screen for both CRC and AAA, CTC is a highly cost-effective and clinically efficacious screening strategy for the Medicare population.
CT colonography (CTC) is a safe and minimally invasive procedure that has shown comparable performance to optical colonoscopy for the detection of advanced neoplasia As a result, the American Cancer Society, in conjunction with the major gastroenterology and radiology societies, has recommended CTC for routine colorectal cancer (CRC) screening for adults ≥50 years old. When a 6-mm polyp size threshold for reporting and polypectomy referral is assumed, CTC screening beginning at age 50 has been shown to be highly cost-effective. These results, however, cannot be directly applied to a Medicare population ≥65 years old.
In addition to the detection of colorectal neoplasia, a unique benefit of CTC screening is the limited evaluation of extracolonic structures of the abdomen and pelvis. A potential disadvantage of this extracolonic evaluation is the occasional need for additional diagnostic imaging related to unsuspected findings. However, in some cases, the detection of relevant extracolonic findings at an early presymptomatic stage may be beneficial. Prime examples include asymptomatic abdominal aortic aneurysm (AAA) and extracolonic malignancies. According to one prior study, the net effect of extracolonic evaluation appears to be positive in terms of life-years gained and overall cost-effectiveness. Cost-effectiveness analyses have also shown that screening for AAA with abdominal ultrasound provides high clinical efficacy at a relatively low cost. With CTC, AAA screening is provided at no extra cost and requires no extra imaging beyond the examination already being performed for CRC screening, thus providing additional benefit to the patient.
In the opening paragraph of their February 2009 proposed decision memo for considering coverage of CTC for CRC screening, the Centers for Medicare and Medicaid Services (CMS) singled out the need for more data about the cost-effectiveness of CTC screening in the Medicare population. Although strong evidence exists about the cost-effectiveness of CTC screening beginning at the age of 50 years, data for a Medicare population ≥65 years old are currently lacking. The aim of this study was to assess the potential clinical efficacy and cost-effectiveness of CTC for CRC screening in the Medicare population relative to both optical colonoscopy and no screening.
Abstract and Introduction
Abstract
Objective. CT colonography (CTC) is a recommended test for colorectal cancer (CRC) screening according to the updated 2008 American Cancer Society guidelines. CTC can also accurately detect abdominal aortic aneurysm (AAA). This collaborative gastroenterology–radiology project evaluated the cost-effectiveness and clinical efficacy of CTC in the Medicare population.
Materials and Methods. A computerized Markov model simulated the development of CRC and AAA in a hypothetical cohort of 100,000 U.S. adults ≥65 years old. Screening with CTC at 5- and 10-year intervals using a 6-mm size threshold for polypectomy was compared with primary optical colonoscopy screening every 10 years and with no screening. Base case costs for CTC and optical colonoscopy were $674 and $795, respectively. The costs of the imaging workup for extracolonic findings at CTC were also included.
Results. CTC resulted in 7,786 and 7,027 life-years gained at 5- and 10-year intervals, respectively, compared with 6,032 life-years gained with 10-year optical colonoscopy. The increase in overall efficacy with CTC was primarily due to prevention of AAA rupture because CRC prevention and CRC detection rates were similar for CTC and optical colonoscopy. All three strategies were highly cost-effective compared with no screening, with an incremental cost-effectiveness ratio (ICER) of $6,088, $1,251, and $1,104 per life-year gained for 5-year CTC, 10-year CTC, and 10-year optical colonoscopy strategies, respectively. The ICER of 5-year CTC and 10-year CTC versus optical colonoscopy was $23,234 and $2,144 per life-year gained, respectively.
Conclusion. Because of its ability to simultaneously screen for both CRC and AAA, CTC is a highly cost-effective and clinically efficacious screening strategy for the Medicare population.
Introduction
CT colonography (CTC) is a safe and minimally invasive procedure that has shown comparable performance to optical colonoscopy for the detection of advanced neoplasia As a result, the American Cancer Society, in conjunction with the major gastroenterology and radiology societies, has recommended CTC for routine colorectal cancer (CRC) screening for adults ≥50 years old. When a 6-mm polyp size threshold for reporting and polypectomy referral is assumed, CTC screening beginning at age 50 has been shown to be highly cost-effective. These results, however, cannot be directly applied to a Medicare population ≥65 years old.
In addition to the detection of colorectal neoplasia, a unique benefit of CTC screening is the limited evaluation of extracolonic structures of the abdomen and pelvis. A potential disadvantage of this extracolonic evaluation is the occasional need for additional diagnostic imaging related to unsuspected findings. However, in some cases, the detection of relevant extracolonic findings at an early presymptomatic stage may be beneficial. Prime examples include asymptomatic abdominal aortic aneurysm (AAA) and extracolonic malignancies. According to one prior study, the net effect of extracolonic evaluation appears to be positive in terms of life-years gained and overall cost-effectiveness. Cost-effectiveness analyses have also shown that screening for AAA with abdominal ultrasound provides high clinical efficacy at a relatively low cost. With CTC, AAA screening is provided at no extra cost and requires no extra imaging beyond the examination already being performed for CRC screening, thus providing additional benefit to the patient.
In the opening paragraph of their February 2009 proposed decision memo for considering coverage of CTC for CRC screening, the Centers for Medicare and Medicaid Services (CMS) singled out the need for more data about the cost-effectiveness of CTC screening in the Medicare population. Although strong evidence exists about the cost-effectiveness of CTC screening beginning at the age of 50 years, data for a Medicare population ≥65 years old are currently lacking. The aim of this study was to assess the potential clinical efficacy and cost-effectiveness of CTC for CRC screening in the Medicare population relative to both optical colonoscopy and no screening.
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