Estimates of costs and effects of screening for colorectal cancer in the United States.
BACKGROUND: In many ways, colorectal cancer might be an excellent candidate for mass screening because of the following: (1) it is the second leading cause of cancer mortality in the United States; (2) it develops slowly from a precursor lesion; and (3) methods of early detection are available. Barriers to screening include unproven efficacy of the procedure and high costs. METHODS: Cost analyses are derived from two mathematic models that estimate screening costs and effects based on expert opinion and data from uncontrolled screening studies. RESULTS: One screening option that follows the guidelines of the American Cancer Society and the National Cancer Institute (annual testing for occult fecal blood and sigmoidoscopy every 5 years) could result in a 40% decrease in colon cancer mortality for American adults between the ages of 50 and 75 years if they comply with screening. This model, developed by David Eddy, projects an average of 44 days of extra life per person screened, at a net cost of $57 per day of life gained. Using assumptions much less favorable to screening, the Office of Technology Assessment modeled this same screening strategy for those aged 65 years and older. This model predicted a similar benefit of extra life per person at a cost of $118 per day of life gained. This doubling of the predicted cost was caused by the inclusion of subsequent colonoscopic surveillance costs for those found to have polyps. Direct costs of screening annually for fecal occult blood and every 5 years by sigmoidoscopy would cost an average of approximately $48 per person per year for screening and follow-up testing of all positive results. Fecal occult blood testing alone, although less effective, costs only $20 per person per year, including follow-up testing of all positive findings. CONCLUSIONS: The results from randomized trials of fecal occult blood screening will be known in the next 5 years, but trials of screening with sigmoidoscopy will not be complete for 10-15 years. Because mass screening programs will be difficult to fund without better data on their efficacy, colorectal cancer screening will continue to be a matter of individual decision making in the clinical setting for years to come. Clearer presentations of costs and benefits that can be understood by both patients and physicians are needed.