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In 2018, the American Cancer Society recommended starting screening for colorectal cancer (CRC) at age 45 in average-risk individuals. This has generated controversy and debate regarding benefits, harms, and costs.
Researchers assessed the cost-effectiveness of screening at age 45 compared with 50, and its effects on resources if adopted nationally. The investigators used a validated Markov model with inputs for CRC risk, screening and surveillance strategies, and costs. The base-case analysis for screening starting at age 45 compared with 50 yielded the following results:
Screening colonoscopy prevented four CRCs and two CRC deaths and gained 14.4 discounted quality-adjusted life years (QALYs) per 1000 persons. This required 758 additional colonoscopies and cost US$33,900/QALY gained.
Using the fecal immunochemical test (FIT) for screening had similar benefits but required 267 additional colonoscopies and cost US$7,700/QALY gained.
A strategy employing annual FIT at ages 45 to 49 with transition to colonoscopy every 10 years at age 50 was highly cost-effective compared with initiating colonoscopy at age 50.
The 758 colonoscopies required to screen 1000 persons beginning at age 45 could instead be allocated to screening 231 currently unscreened 55-year-olds or 342 unscreened 65-year-olds, with greater benefit (13–14 CRC cases and 6–7 CRC deaths prevented), and with savings up to US$450,000.
Ladabaum U et al. Cost-effectiveness and national effects of initiating colorectal cancer screening for average-risk persons at age 45 years instead of 50 years. Gastroenterology 2019 Mar 28; [e-pub]. (https://doi.org/10.1053/j.gastro.2019.03.023)
Comment
This well-performed modeling analysis is likely to provide support for both proponents and opponents of lowering the CRC screening age to 45. A longer-term key question is whether we can have our cake and eat it, too — i.e., lower the screening age while also sustaining efforts and resources needed to reach older unscreened individuals. Clinical studies of CRC screening in average-risk persons aged 45 to 49 are sorely needed.