Benefits Of Colorectal Cancer Screening Research Articles

Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication

BackgroundEarly detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response.MethodsUsing both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention.ResultsData from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p < 0.01) and was sustained at month 4 following the intervention.ConclusionElectronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.

Social and cultural factors are related to perceived colorectal cancer screening benefits and intentions in African Americans.

Models that explain preventive behaviors, such as colorectal cancer (CRC) screening, do not account for social and cultural factors relevant to African Americans. This exploratory study examined the relationship between socio-cultural factors (e.g., traditional acculturative strategy, group-based medical mistrust, physician ethnicity, and group-level perceptions of susceptibility) and perceived benefits, perceived barriers, and CRC screening intentions among African Americans (N = 198; Age: M = 59.7, SD = 9.9; 65% female; 44% household income $50,000+). Hierarchical multiple regression was used to test the following models with perceived benefits, perceived barriers, and screening intentions as the outcomes: (a) traditional acculturative strategy x medical mistrust; (b) physician's ethnicity x medical mistrust; (c) group susceptibility x medical mistrust; and (d) group susceptibility x traditional acculturative strategy. Results revealed that perceiving high group susceptibility while being both more culturally traditional and less mistrustful was associated with more perception of screening benefits. Greater intention to be screened was associated with perceiving high group susceptibility while having a more traditional cultural orientation and low levels of mistrust in those with African American physicians. These results suggest that it may be beneficial to include these social and cultural factors in behavioral interventions to increase CRC screening among African Americans.

Patient Initiated Promoting of Physician Resulted in Increased Referrals for Colorectal Cancer Screening

Purpose: Colorectal Cancer is the third leading cause of cancer-related mortality in the United States. Despite the proven benefit of colorectal cancer screening (CRC-S), only about 50% of eligible patients in the US are screened. Interventions as attempts to increase the referral for CRC-S are lacking. The purpose of this study is to determine whether a communication tool provided to patients will initiate a conversation with their primary care physicians about CRC-S and whether this tool will impact referral patterns for screening, especially, among poor and underserved populations. Methods: From November 2008 to June 2009, patients were screened in the medicine resident clinic waiting area for eligibility for CRC-S. Patients were randomly assigned to control group or intervention group, in which a pamphlet about the benefit of CRC-S were given to patients before seeing their physicians. Primary endpoint was the rate of referrals for CRC-S. Statistical analysis was done using the SAS software (v 9.1.3) with p-value set at 0.05. Results: A total of 148 patients, 72 (40F:32M) in the control group and 76 (48F:28M) in the intervention group, were analyzed. No differences in baseline characteristics among two groups. 45/72 (63%) in the control group got referrals for CRC-S versus 70/76 (92%) in the intervention group (p = <0.0001). However, 31/45 (69%) in the control group accepted the referrals versus 41/70 (59%) in the intervention group (p = NS). Colonoscopy was the recommended procedure for all patients. Patients were not recommended any other CRC-S methods when they turned down colonoscopy. The most common factor that influenced patients' decision to postpone the referrals was financial difficulty, 11/14 (79%) in control group versus 20/29 (69%) in study group. Fear of the bowel preparation, procedure complications, unsure of the benefit of colonoscopy, and fear of finding cancers were other less common reasons for not accepting the referrals. Conclusion: Patient initiated prompting of physicians resulted in a significant increase in the numbers of referrals for CRC-S. The total numbers of patients who accepted CRC-S was higher in the intervention group, although not statistically significant. Further investigation directed towards increasing the acceptance of CRC-S in this population is warranted.

Physician and Gender Differences Among the Patient-Physician Discussion Prior to Open Access Colonoscopy

Objective: In an effort to improve colorectal cancer screening (CRCS) compliance, open-access colonoscopy (OAC) is utilized to decrease the cost and waiting time for colonoscopy. The purpose of our study was to examine the patient-physician discussion prior to OAC to assess areas to improve CRCS compliance. Methods: A questionnaire was administered to consecutive patients undergoing OAC at a private gastroenterology practice. Patients reported demographics, provider information, discussion length, and content areas of the discussion. Results: 426 subjects completed the questionnaire of which 52% were women. 70.4% of participants were Caucasian and 22.1% were African American. The average age was 52.8 (+5.3) yrs. Subjects had seen their primary care physicians (PCP) for 7.9(+7.6) yrs and averaged two visits/yr. 63% of PCPs were male. 47.2% of referring physicians were family practice(FP), 39.2% were internists(IM), and 8.9% were gynecologists(GYN). Male subjects reported a mean 9.7 +4.3 minutes of discussion about CRCS, colonoscopy procedure and preparation compared to women subjects at 7.6 +4.3 min. The female physicians' discussions were slightly longer than their male cohorts, 11.2 +1.9 vs. 10.8 +1.9 min, respectively. FPs(12.6 +4.1 min) had the most extensive discussion regarding CRCS/OAC relative to IM(7.8 +4.0 min) and GYN(6.7 +4.8 min). 25% of subjects discussed other CRCS methods besides colonoscopy. Women were less likely than men to have discussed other forms of CRCS(OR 0.36, p<0.000). 57% of subjects discussed the benefits of CRCS. GYNs (OR 9.5, p<0.005) and IMs (OR 4.3, p<0.042) were most likely to discuss benefits of CRCS with subjects. 20% of subjects reported discussing the risks of OAC and 23% reported discussing the medications to avoid. Only 52% felt that they were adequately informed prior to OAC. Women were half as likely to be adequately informed by their practitioner (OR 0.40, p<0.000), the risks of colonoscopy (OR 0.45, p<0.005) and medications to avoid(OR 0.51, p<0.012). Of all PCPs, women felt that GYNs best informed them about their procedure (OR 12.5, p<0.005). Subjects with a relationship for 10 years or greater with their doctor were 43% more likely to be adequately informed(OR 1.43, p<0.00). Female physicians were the most influential in a patient's decision to undergo a colonoscopy (OR 1.63, p<0.04). Conclusion: Despite the time devoted by PCPs, patients do not feel well informed about CRCS. Specifically, women are least likely to be informed about the CRCS process. In continuing to improve CRCS compliance, strategies must be in place to prompt PCPs to discuss the CRCS process with their patients.

Identification d’allèles de susceptibilité au cancer colorectal à faible pénétrance

Colorectal cancer affects over 500,000 individuals yearly. Much of the benefit of colorectal cancer screening has been attributed to detection and removal of adenomatous polyps, highlighting the importance of colorectal polyps as targets for intervention and as biomarkers for colorectal cancer risk. Positive familial history (first or second degree relative) for colorectal carcinoma can be found in approximately 30% of all newly diagnosed cases, but less than 5% will be due to a defined genetic category of hereditary CRC. Genome-wide association studies have identified multiple loci at which common variants modestly influence the risk of developing colorectal cancer. The risks conferred by the susceptibility alleles are low. The combined effects may, however, be sufficiently large to be useful for risk prediction, and targeted screening and prevention, particularly as more loci are identified.

Colorectal Polyps: The Scope and Management of the Problem

Colorectal cancer affects over 150,000 individuals yearly, and accounts for over 50,000 deaths. Much of the benefit of colorectal cancer screening has been attributed to detection and removal of adenomatous polyps, highlighting the importance of colorectal polyps as targets for intervention and as biomarkers for colorectal cancer risk. This review details the epidemiology of sporadic colorectal polyps, rationale behind use of polyps as an important surrogate for colorectal cancer risk, the benefits and limitations of secondary prevention of colorectal polyps through chemopreventive and dietary interventions, as well as colon surveillance.

Colorectal Cancer Screening and African Americans: Findings from a Qualitative Study

Colorectal cancer (CRC) screening has been found to be an effective tool for the control and prevention of this type of cancer, yet it is underutilized by African Americans. Consequently, African Americans with CRC are diagnosed at late stages and suffer disproportionately higher mortality rates for CRC. To understand factors that influence the decision to participate in CRC screening, in-depth personal interviews were conducted with 36 African Americans in the Washington, DC, metropolitan area. Predisposing factors, enabling factors, and reinforcing factors were identified and categorized using the Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation (PRECEDE) framework. Findings suggest that distinct differences exist between individuals who are adherent to screening guidelines and those who have not undergone screening. Adherent individuals were more knowledgeable about CRC and held positive beliefs about the benefits of screening. Nonadherent individuals placed little importance on prevention and early detection. Physician recommendation and insurance coverage/cost also differentiated the two groups. Study findings suggest that efforts to increase awareness and promote the benefits of CRC screening are needed among African Americans. Also, efforts by healthcare providers to recommend CRC screening are important in promoting adherence. Further, low- or no-cost CRC screening is needed to increase participation by individuals who are economically disadvantaged.

Physician–Patient Communication about Colorectal Cancer Screening

Despite the documented benefits of colorectal cancer screening, patient participation rates remain low. Physician recommendation has been identified as a significant predictor of screening completion. The aim of this study is to investigate how primary care physicians perceive colorectal cancer screening communication tasks, as well as to explore the form and content of actual screening discussions. The research design includes a mailed physician survey and a separate observational study in a sample of videotaped medical encounters. PARTICIPANTS AND DATA SOURCES: The participants were 270 primary care physicians who completed a mailed questionnaire (57.9% response rate) and 18 physician-patient encounters that included discussions of colorectal cancer screening. The questionnaire focused on perceived importance and accomplishment of communication tasks relevant to colorectal cancer screening. Two of the authors reviewed transcripts of videotaped physician encounters to determine whether the same communication tasks assessed in the survey were accomplished. Interrater reliability was high across all of the mutually exclusive coding categories (Kappa > .90). Physicians rated colonoscopy as the most important screening option to discuss; self-reports indicate that colonoscopy (84.8%) is more frequently mentioned than fecal occult blood test (FOBT; 49.4%), flexible sigmoidoscopy (34.1%), or computed tomography (CT) imaging (18.1%). Explaining benefits and risks, describing test procedure and frequency, eliciting patient preferences, and making a plan for screening were all viewed as very important. Self-reported accomplishment of these communication tasks was considerably higher than that observed in our separate videotape sample. Most physicians recognize and espouse the importance of recommending colorectal cancer screening to eligible patients. However, findings from both the physician survey and observational study suggest that physicians tend to overestimate the extent of discussions about screening. Interventions may be warranted to improve clinical practice.

Patient Support Program Increases Adherence to Colorectal Cancer Screening

Purpose: Support system limitations to ensure completion of testing or procedure contributes to the lack of colorectal cancer (CRC) screening. Previously a patient adherence and tracking pilot program associated with stool DNA (sDNA) screening was shown to have improved patient adherence (Am J Gastroenterology 2005;100(9):S394). The effect of an enhanced enrollment-based patient support system on test adherence for sDNA–a test intended for patients unwilling, unable, or who were noncompliant with colonoscopy–was studied during the first five months of 2006. Methods: Patients who were prescribed an sDNA test during 2006 were given the option to enroll in a nationwide patient support program titled PreGen-CaresSM (PGC). The enrollment process included patient authorization and enabled the PGC staff to contact the patient directly by phone several days after the office visit to: enhance patient education and reinforce the need for screening, ensure proper at-home stool collection, arrange for specimen transport via overnight mail, provide timely feedback to the clinician, and collect outcomes data. Follow-up contacts were attempted 7–10 days after initial contact to provide patient reminders and facilitate the specimen submission process. A case was considered closed if either the patient submitted a specimen or failed to submit a specimen within 5 weeks of first contact. If the patient failed to submit a specimen, a letter was sent to both patient and clinician to close the case. Results: 1440 patients were enrolled. While 220 of the 1440 patient cases are open pending testing completion, 885 tests out of the 1220 closed cases were completed, yielding an adherence rate of 73%. Twenty-one of the 1220 closed-case enrollees declined the stool DNA test; however, the PGC staff discussed the benefits of CRC screening with these enrollees and the enrollees agreed to recontact their health care providers to schedule the original colonoscopy they were initially unwilling to complete. Conclusions: Patient adherence with CRC screening benefits from an educational and follow-up program, which augments communication between patient and physician, addresses questions that arise before or during testing, increases testing convenience and emphasizes the importance of regular CRC screening. Support system and infrastructure increase compliance with CRC screening recommendations.

Comparing Risks and Benefits of Colorectal Cancer Screening in Elderly Patients

Comparing Risks and Benefits of Colorectal Cancer Screening in Elderly Patients

Disparities Despite Coverage

Despite its effectiveness in reducing mortality, colorectal cancer (CRC) screening rates are low, especially among low-income and minority groups; however, physician recommendation can increase screening rates. We performed a multilevel analysis of the Medicare Current Beneficiary Survey data linked to Medicare claims and the Area Resource File to identify determinants of racial and socioeconomic disparities in CRC screening among 9985 Medicare Parts A and B beneficiaries with a usual physician. Recent CRC screening was defined as receipt of either a home fecal occult blood test, flexible sigmoidoscopy, or colonoscopy at recommended intervals. Unadjusted rates of screening were 48% for white and 39% for black beneficiaries (P<.001). Racial differences in CRC screening receipt were eliminated after adjustment for socioeconomic status as measured by income and education. Socioeconomic status disparities decreased but remained significant after adjustment for personal and health system factors. Awareness of CRC (adjusted odds ratio, 2.76; 95% confidence interval, 2.29-3.33) and having a primary care generalist (vs another specialist) as one's usual physician (adjusted odds ratio, 1.31; 95% confidence interval, 1.12-1.53) were associated with higher odds of screening, controlling for other factors. The odds of screening were also higher among those whose usual physician was rated more highly on information-giving skills. Racial differences in CRC screening rates among Medicare beneficiaries with a usual physician are explained by differences in socioeconomic status. Beneficiaries with a primary care generalist as their usual physician had higher rates of CRC screening receipt. Increased efforts to make Medicare beneficiaries aware of the benefits of CRC screening may capitalize on the associations found in this study between CRC knowledge, physician information giving, and timely screening.

This Month in Gastroenterology

This Month in Gastroenterology

Comparing Risks and Benefits of Colorectal Cancer Screening in Elderly Patients

In patients with limited life expectancy, the risks of colorectal cancer screening may outweigh the benefits. The aim of this study was to quantify risks and benefits of different screening strategies in elderly patients with varying life expectancies. We examined risks and benefits of screening in patients aged 70-94 years with differing health status using 3 strategies: annual fecal occult blood tests, flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. We compared the number needed to screen to prevent one cancer-related death and the number needed to encounter one screening-related complication for different strategies. The potential benefit from screening varied widely with age, life expectancy, and screening modality. One cancer-related death would be prevented by screening 42 healthy men aged 70-74 years with colonoscopy, 178 healthy women aged 70-74 years with fecal occult blood tests, 431 women aged 75-79 years in poor health with colonoscopy, or 945 men aged 80-84 years in average health with fecal occult blood tests. Colonoscopy screening had the greatest benefit but the highest risk of complications. The potential for screening-related complications was greater than estimated benefit in some population subgroups aged 70 years and older. At all ages and life expectancies, the potential reduction in mortality from screening outweighed the risk of colonoscopy-related death. The potential benefits and risks of screening vary in elderly patients of different life expectancies. For any individual patient, the potential for harm from screening must be weighed against the likelihood of benefit, especially with shorter life expectancy.

The Hidden Value of Upper Endoscopy: A “Teachable Moment” for Colorectal Cancer Screening

The Hidden Value of Upper Endoscopy: A ‘‘Teachable Moment’’ for Colorectal Cancer Screening Stacy B. Menees, A.M. Fendrick, Ruth Carlos, James Scheiman Background: Nearly half of Americans do not undergo colorectal cancer (CRC) screening as recommended by professional organizations. Those individuals inadequately screened for CRC who are referred for open access esophagoduodenoscopy (EGD) represent an opportunity for gastroenterologists to provide education regarding the benefits of CRC screening and ultimately enhance adherence rates. CRC screening rates for eligible individuals undergoing upper access EGD has not been established. Aims: 1. Determine the rate of CRC screening among a cohort of patients undergoing direct access EGD for whom screening is recommended; 2. Determine predictors of CRC screening in this population. Methods: A retrospective chart review of 1076 consecutive patients undergoing open access EGD from January 2003 to June 2004 was undertaken at a large Midwestern academic medical center to determine compliance with CRC screening recommendations. Only patients followed by a primary care provider (PCP) at this same institution for at least one year were eligible. Demographic, insurance coverage, duration of primary care physician relationship and other preventive care services were analyzed to determine predictors of CRC screening. Results: Of the 247 individuals undergoing EGD who met inclusion criteria and were eligible for CRC screening (57% women, 84% Caucasian, mean age 60 years, mean primary physician relationship 5.5 years), 68% were up to date with CRC screening. Significant predictors of screening included younger age (aged 55-59 and 60-64 (OR Z 3.01, 95% CI 2.22,7.42; OR Z 4.04, 95%CI 1.56,10.19), adherence to non-CRC cancer screening (OR Z 3.70, 95%CI 1.49,9.20) and a PCP relationship of 9 years or greater (OR Z 2.34, 95% CI 1.22,4.05). Female gender was a significant negative predictor of CRC screening (OR Z 0.38, 95%CI 0.18,0.80). Conclusion: At the time of open access EGD, one-third of patients who would benefit from CRC screening were not compliant with recommended guidelines. Male gender, younger age, longer doctor-patient relationships, and compliance with preventive health behaviors were associated with CRC screening. The EGD experience – especially for women may represent a ‘‘teachable moment’’ to Abstracts

SCREENING FOR COLORECTAL CANCER IN ITALY

Purpose: In Italy Colorectal Cancer (CRC) is responsible for more than 35,000 new cases and almost 17,000 deaths annually. Epidemiological data show that CRC is the second most frequent cancer in incidence and mortality for both sexes. A legislation allowing free screening colonoscopy (TC) in average risk subjects was enacted in 2001, but screening by fecal occult blood (FOBT) is also ongoing in several Regions. Purpose A preliminary study to assess the rate of compliance to the different screening modalities in various Regions, the yield of significant lesions and the quality parameters of FOBT and TC. A RCT based on guaiac FOBT on three consecutive samples (directly developed by GPs) or TC in asymptomatic average risk subject, age 55–64 years, without familiarity, in 9 out of 20 Italian Regions, involving 14 Endoscopy Units. Eligible subjects are directly invited from their GPs and randomized to one of the two tests. The preliminary results of the first round of screening are reported, being the study still ongoing. 7,776 subjects were contacted and 1,129 (14.5%) were excluded by protocol. The remaining 6,647 were invited by letter and non-compliers reminded by subsequent phone call. The overall compliance is, up to now, 18.9% for both tests, being 32.0% for FOBT (range 7.9-60%) and 7.4% for TC (range 0–54.9%). Overall rate of FOBT positivity is 11.1% (range 0.8-48%), but excluding the GP with 48% of positive tests, the rate drops to 5.6%. The compliance to tests differs in northern, central and southern Italian areas. The interest and compliance to free screening colonoscopy is low, with wide variability between GPs, Endoscopy Units and Regions, with a well defined North-South trend. Lack of awareness on the benefits of CRC screening, embarrassment in discussing bowel matters with GPs and fear of cancer diagnosis are among the possible explanations for the low compliance, as shown by the results of an European survey made by the United European Gastroenterology Federation.Table 1

Screening men for prostate and colorectal cancer in the United States: does practice reflect the evidence?

The debate about the efficacy of prostate-specific antigen (PSA) screening for prostate cancer has received substantial attention in the medical literature and the media, but the extent to which men are actually screened is unknown. If practice were evidence-based, PSA screening would be less common among men than colorectal cancer screening, a preventive service of broad acceptance and proven efficacy. To compare the prevalences of PSA and colorectal cancer screening among US men. The 2001 Behavioral Risk Factor Surveillance System, an annual population-based telephone survey of US adults conducted by the Centers for Disease Control and Prevention, was used to gather data on a representative sample of men aged 40 years or older from all 50 states and the District of Columbia (n = 49 315). Proportions of men ever screened and up to date on screening for prostate cancer (with PSA testing) and colorectal cancer (with fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy). Overall, men are more likely to report having ever been screened for prostate cancer than for colorectal cancer; 75% of those aged 50 years or older have had a PSA test vs 63% for any colorectal cancer test (risk ratio [RR], 1.20; 95% confidence interval [CI], 1.18-1.21). Up-to-date PSA screening is also more common than colorectal cancer screening for men of all ages. Among men aged 50 to 69 years (those for whom there is the greatest consensus in favor of screening), 54% reported an up-to-date PSA screen, while 45% reported up-to-date testing for colorectal cancer (RR, 1.19; 95% CI, 1.16-1.21). In state-level analyses of this age group, men were significantly more likely to be up to date on prostate cancer screening compared with colorectal cancer screening in 27 states, while up-to-date colorectal cancer screening was more common in only 1 state. Among men in the United States, prostate cancer screening is more common than colorectal cancer screening. Physicians should ensure that men who choose to be screened for cancer are aware of the known mortality benefit of colorectal cancer screening and the uncertain benefits of screening for prostate cancer.

Colorectal cancer screening practices among attendees at a cancer screening clinic.

Little is known about colorectal cancer (CRC) screening behaviors among patients seen in a general cancer screening clinic. Age-eligible respondents completed a brief self-administered survey examining self-reported compliance with CRC screening recommendations and beliefs about the benefits of CRC screening. Overall compliance with CRC screening among respondents was 43%. Although compliance did not differ by gender, persons aged 65+ years were more than five times more likely to be compliant with CRC screening (OR = 5.29, CI = 2.06-13.58). While a majority of respondents (87%) reported that they would complete CRC screening if recommended by a doctor, only 54% had talked with their doctors about examinations for CRC. Males were more likely to report they would complete testing if recommended by their doctors (OR = 6.81, CI = 1.46-31.8) and twice as likely to report having talked to their doctors about CRC testing (OR = 2.71, CI = 1.32-5.56). Efforts to enhance CRC screening behaviors among motivated subpopulations seeking preventive care might consider opportunities to augment physician-patient dialogues regarding the need for screening tests. In addition, the dissonance between the recognized need for CRC testing and lack of compliance warrants further examination.

Colorectal cancer screening beliefs. Focus groups with first-degree relatives.

The purpose of this paper is to describe the perceived benefits and barriers to colorectal cancer screening reported by first-degree relatives of colorectal cancer patients. In this study, the authors used focus groups to identify perceived benefits and barriers to colorectal cancer screening among parents and children of colorectal cancer patients. Four focus groups were conducted with relatives of colorectal cancer patients seen at two university medical centers in the Midwest. The groups ranged in size from five to eight members each and were stratified by gender. Four benefits of colorectal cancer screening were identified by participants: finding colorectal cancer early, decreasing the chances of dying from colorectal cancer, freedom from worry about colorectal cancer, and reassurance that one was cancer-free. Four main barriers were identified that applied to all four types of colorectal cancer screening or to colorectal cancer screening in general. These included inadequate public awareness of colorectal cancer, inconsistent recommendations from healthcare providers, concerns about the efficacy of screening tests, and embarrassment. Barriers unique to each screening test also were identified. Understanding individual beliefs about the benefits and barriers to colorectal cancer screening will allow clinicians and researchers to develop effective interventions to increase screening. Results from the focus groups have been used to develop an instrument to measure benefits and barriers to colorectal cancer screening, which now needs to be tested with more culturally and socioeconomically diverse groups.

Cost‐effectiveness analysis of screening by faecal occult blood testing for colorectal cancer in Australia

The incremental costs and effects of annual faecal occult blood test screening in Australia were modelled for a hypothetical cohort of 1000 persons offered screening or not offered screening. Incremental costs and effects were estimated as the differences in direct health care costs (Australian costs) and years of life remaining between the annual-screen group and the control (no screen) group, based on the published results of the Minnesota randomised controlled trial. The cost per life year saved was $24,660. The greatest source of variability in the cost-effectiveness ratio is the effectiveness of screening. The 95 percent confidence interval for cumulative mortality in the annual-screen group is 3.86 to 7.9 per 1000, assuming the control rate is fixed at 8.83 per 1000. With this confidence interval, the cost per life year saved ranges from $12,695 to $67,848. The cost-effectiveness ratio increases to $48,000 if no mortality benefit is assumed beyond the end of the trial follow-up period, 13 years. The results are sensitive to the cost of colonoscopy (at $400 per colonoscopy, the cost per life year saved is $12,319) and the false-positive rate. The cost-effectiveness of colorectal cancer screening is comparable with that of other screening programs but further evidence is needed on the efficacy of screening. Whether the benefits of colorectal cancer screening outweigh the harm and costs needs to be more certain before more resources are committed to mass screening. Health policy planners should initiate planning for Australian pilot projects in the event that the efficacy of screening is confirmed by two current studies.

Effect of workup strategy on the cost-effectiveness of fecal occult blood screening for colorectal cancer

Physicians respond to a positive fecal occult blood test with a variety of workup strategies. To study the effect of the choice of strategy on the net costs and health benefits of colorectal cancer screening using this test, we used a decision analysis model to compare seven strategies that physicians might choose to examine a positive “screenee.” Strategies using rigid or flexible sigmoidoscopy alone are not only insensitive, but also have high cost-effectiveness ratios. The strategy of air contrast barium enema alone had the lowest cost-effectiveness ratio. Rigid sigmoidoscopy combined with barium enema had a lower cost-effectiveness ratio than primary colonoscopy, but the strategy of primary colonoscopy could have an equal or better ratio depending on assumptions about test costs and the benefit of removing benign polyps. The primary colonoscopy strategy is both more effective and less costly than the combination of flexible sigmoidoscopy and barium enema. The optimal strategy will vary with local factors, and with the perspective of the decision-maker.