Age-specific sequence of colorectal cancer screening options in Germany: A model-based critical evaluation

Thomas Heisser,Korbinian Weigl,Hermann Brenner,Michael Hoffmeister,Driss Ait Ouakrim

doi:10.1371/journal.pmed.1003194

Abstract

BackgroundThe current organized screening program for colorectal cancer in Germany offers both sexes 5 annual fecal immunochemical tests (FITs) between ages 50 and 54 years, followed by a first screening colonoscopy at age 55 years if all of these FITs were negative. We sought to assess the implications of this approach for key parameters of diagnostic performance.Methods and findingsUsing a multistate Markov model, we estimated the expected detection rates of advanced neoplasms (advanced adenomas and cancers) and number needed to scope (NNS) to detect 1 advanced neoplasm at a first screening colonoscopy conducted at age 55 after 5 preceding negative FITs and compared them with the corresponding estimates for a first screening colonoscopy at age 55 with no preceding FIT testing. In individuals with 5 consecutive negative FITs undergoing screening colonoscopy at age 55, expected colonoscopy detection rate (NNS) was 3.7% (27) and 0.10% (1,021) for any advanced neoplasm and cancer, respectively, in men, and 2.1% (47) and 0.05% (1,880) for any advanced neoplasm and cancer, respectively, in women. These NNS values for detecting 1 advanced neoplasm are approximately 3-fold higher, and the NNS values for detecting 1 cancer are approximately 8-fold higher, than those for a first screening colonoscopy at age 55 without prior FITs. This study is limited by model simplifying assumptions and uncertainties related to input parameters.ConclusionsScreening colonoscopy at age 55 after 5 consecutive negative FITs at ages 50–54, as currently offered in the German cancer early detection program, is expected to have very low positive predictive value. Our results may inform efforts to enhance the design of screening programs.

Highlights

Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer and the third leading cause of cancer death in Europe, accounting for approximately 60,000 new cancer cases and approximately 25,000 cancer deaths every year in Germany alone [1,2]
As the assumption of a perfectly adhering population is unrealistic in practice, we simulated alternative fecal immunochemical test (FIT) screening strategies with longer intervals between test rounds, which are equivalent to reduced uptake of 60%, 40%, and 20% of offered FIT screening: (1) 3 FITs at ages 50, 52, and 54, (2) 2 FITs at ages 50 and 53 (2 out of 5), and (3) 1 FIT at age 50 (1 out of 5), all of these followed by screening colonoscopy at age 55
Of the simulated population of 100,000 men and 100,000 women with preceding annual FIT screening, 52% of men and 74% of women were eligible for screening colonoscopy at age 55

Summary

Introduction

Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer and the third leading cause of cancer death in Europe, accounting for approximately 60,000 new cancer cases and approximately 25,000 cancer deaths every year in Germany alone [1,2]. Screening approaches recommended by international expert panels [8] and offered in screening programs across Europe [9] include colonoscopy, sigmoidoscopy, and fecal immunochemical tests (FITs) for hemoglobin. Typically just 1 screening approach is offered as the primary screening test. The current organized screening program for colorectal cancer in Germany offers both sexes 5 annual fecal immunochemical tests (FITs) between ages 50 and years, followed by a first screening colonoscopy at age years if all of these FITs were negative. We sought to assess the implications of this approach for key parameters of diagnostic performance

Methods

Results

Conclusion