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Impact of Comorbidity on Colorectal Cancer Screening Cost-Effectiveness Study in Diabetic Populations

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ABSTRACT

BACKGROUND

Although comorbidity has been shown to affect the benefits and risks of colorectal cancer (CRC) screening, it has not been accounted for in prior cost-effectiveness analyses of CRC screening.

OBJECTIVE

To evaluate the impact of diagnosis of diabetes mellitus, a highly prevalent comorbidity in U.S. adults aged 50 and older, on health and economic outcomes of CRC screening.

DESIGN

Cost-effectiveness analysis using an integrated modeling framework.

DATA SOURCES

Derived from basic and epidemiologic studies, clinical trials, cancer registries, and a colonoscopy database.

TARGET POPULATION

U.S. 50-year-old population.

TIME HORIZON

Lifetime.

PERSPECTIVE

Costs are based on Medicare reimbursement rates.

INTERVENTIONS

Colonoscopy screening at ten-year intervals, beginning at age 50, and discontinued after age 50, 60, 70, 80 or death.

OUTCOME MEASURES

Health outcomes and cost effectiveness.

RESULTS OF BASE-CASE ANALYSIS

Diabetes diagnosis significantly affects cost-effectiveness of CRC screening. For the same CRC screening strategy, a person without diabetes at age 50 gained on average 0.07–0.13 life years more than a person diagnosed with diabetes at age 50 or younger. For a population of 1,000 patients diagnosed with diabetes at baseline, increasing stop age from 70 years to 80 years increased quality-adjusted life years (QALYs) gained by 0.3, with an incremental cost-effectiveness ratio of $206,671/QALY. The corresponding figures for 1,000 patients without diabetes are 2.3 QALYs and $46,957/QALY.

RESULTS OF SENSITIVITY ANALYSIS

Cost-effectiveness results are sensitive to cost of colonoscopy and adherence to colonoscopy screening.

LIMITATIONS

Results depend on accuracy of model assumptions.

CONCLUSION

Benefits of CRC screening differ substantially for patients with and without diabetes. Screening for CRC in patients diagnosed with diabetes at age 50 or younger is not cost-effective beyond age 70. Screening recommendations should be individualized based on the presence of comorbidities.

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References

  1. Jemal A, Siegel R, Xu J, Ward E. Cancer Statistics, 2010. CA Cancer J Clin.

  2. Mandel JS, Bond JH, Church TR, Snover DC, Bradley GM, Schuman LM, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med. 1993;328(19):1365–71.

    Article  PubMed  CAS  Google Scholar 

  3. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med. 1992;326(10):653–7.

    Article  PubMed  CAS  Google Scholar 

  4. Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JM, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet;375(9726):1624-33.

  5. Walter LC, Lindquist K, Nugent S, Schult T, Lee SJ, Casadei MA, et al. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med. 2009;150(7):465–73.

    PubMed  Google Scholar 

  6. Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, van Ballegooijen M, Kuntz KM. Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(9):659–69.

    PubMed  Google Scholar 

  7. Calkins E, Boult C, Wagner E. New ways to care for older people. Building systems based on evidence. New York: Springer; 1999.

    Google Scholar 

  8. Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA. 2003;290(14):1884–90.

    Article  PubMed  CAS  Google Scholar 

  9. Franco OH, Steyerberg EW, Hu FB, Mackenbach J, Nusselder W. Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med. 2007;167(11):1145–51.

    Article  PubMed  Google Scholar 

  10. Gross CP, McAvay GJ, Krumholz HM, Paltiel AD, Bhasin D, Tinetti ME. The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening. Ann Intern Med. 2006;145(9):646–53.

    PubMed  Google Scholar 

  11. Larsson SC, Giovannucci E, Wolk A. Diabetes and colorectal cancer incidence in the cohort of Swedish men. Diabetes Care. 2005;28(7):1805–7.

    Article  PubMed  Google Scholar 

  12. Larsson SC, Orsini N, Wolk A. Diabetes mellitus and risk of colorectal cancer: a meta-analysis. J Natl Cancer Inst. 2005;97(22):1679–87.

    Article  PubMed  Google Scholar 

  13. Gatto NM, Frucht H, Sundararajan V, Jacobson JS, Grann VR, Neugut AI. Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Cancer Inst. 2003;95(3):230–6.

    Article  PubMed  Google Scholar 

  14. Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008;134(5):1570–95.

    Article  PubMed  CAS  Google Scholar 

  15. Kahn R, Alperin P, Eddy D, Borch-Johnsen K, Buse J, Feigelman J, et al. Age at initiation and frequency of screening to detect type 2 diabetes: a cost-effectiveness analysis. Lancet;375(9723):1365-74.

  16. Schlessinger L, Eddy DM. Archimedes: a new model for simulating health care systems–the mathematical formulation. J Biomed Inform. 2002;35(1):37–50.

    Article  PubMed  Google Scholar 

  17. Eddy D, Schlessinger L, Kahn R, Peskin B, Schiebinger R. Relationship of insulin resistance and related metabolic variables to coronary artery disease: a mathematical analysis. Diabetes Care. 2009;32(2):361–6.

    Article  PubMed  CAS  Google Scholar 

  18. Eddy DM, Schlessinger L. Archimedes: a trial-validated model of diabetes. Diabetes Care. 2003;26(11):3093–101.

    Article  PubMed  Google Scholar 

  19. Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Ann Intern Med. 2005;143(4):251–64.

    PubMed  Google Scholar 

  20. Eddy DM, Schlessinger L. Validation of the archimedes diabetes model. Diabetes Care. 2003;26(11):3102–10.

    Article  PubMed  Google Scholar 

  21. Clinical Outcomes Research Initiative, www.cori.org. 2007 (Accessed December 2011)..

  22. Surveillance Epidemiology and End Results (SEER) Program Populations (1969-2006) (www.seer.cancer.gov/popdata) NCI, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released February 2009. (Accessed December 2011).

  23. Tobi M. Polyps as biomarkers for colorectal neoplasia. Front Biosci. 1999;4:D329–38.

    Article  PubMed  CAS  Google Scholar 

  24. Rutter CM, Yu O, Miglioretti DL. A hierarchical non-homogenous Poisson model for meta-analysis of adenoma counts. Stat Med. 2007;26(1):98–109.

    Article  PubMed  Google Scholar 

  25. Welin S, Youker J, Spratt JS Jr. The Rates and Patterns of Growth of 375 Tumors of the Large Intestine and Rectum Observed Serially by Double Contrast Enema Study (Malmoe Technique). Am J Roentgenol Radium Ther Nucl Med. 1963;90:673–87.

    PubMed  CAS  Google Scholar 

  26. Bolin S, Nilsson E, Sjodahl R. Carcinoma of the colon and rectum–growth rate. Ann Surg. 1983;198(2):151–8.

    Article  PubMed  CAS  Google Scholar 

  27. Umetani N, Masaki T, Watanabe T, Sasaki S, Matsuda K, Muto T. Retrospective radiographic analysis of nonpedunculated colorectal carcinomas with special reference to tumor doubling time and morphological change. Am J Gastroenterol. 2000;95(7):1794–9.

    Article  PubMed  CAS  Google Scholar 

  28. Matsui T, Tsuda S, Yao K, Iwashita A, Sakurai T, Yao T. Natural history of early colorectal cancer: evolution of a growth curve. Dis Colon Rectum. 2000;43(10 Suppl):S18–22.

    Article  PubMed  CAS  Google Scholar 

  29. Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329(27):1977–81.

    Article  PubMed  CAS  Google Scholar 

  30. Winawer SJ, Flehinger BJ, Schottenfeld D, Miller DG. Screening for colorectal cancer with fecal occult blood testing and sigmoidoscopy. J Natl Cancer Inst. 1993;85(16):1311–8.

    Article  PubMed  CAS  Google Scholar 

  31. Chao A, Connell CJ, Cokkinides V, Jacobs EJ, Calle EE, Thun MJ. Underuse of screening sigmoidoscopy and colonoscopy in a large cohort of US adults. Am J Public Health. 2004;94(10):1775–81.

    Article  PubMed  Google Scholar 

  32. Higginbotham S, Zhang ZF, Lee IM, Cook NR, Giovannucci E, Buring JE, et al. Dietary glycemic load and risk of colorectal cancer in the Women's Health Study. J Natl Cancer Inst. 2004;96(3):229–33.

    Article  PubMed  CAS  Google Scholar 

  33. Beresford SA, Johnson KC, Ritenbaugh C, Lasser NL, Snetselaar LG, Black HR, et al. Low-fat dietary pattern and risk of colorectal cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. 2006;295(6):643–54.

    Article  PubMed  CAS  Google Scholar 

  34. Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JM, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet. 2010;375(9726):1624–33.

    Article  PubMed  Google Scholar 

  35. Lieberman DA, Weiss DG, Bond JH, Ahnen DJ, Garewal H, Chejfec G. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med. 2000;343(3):162–8.

    Article  PubMed  CAS  Google Scholar 

  36. Winawer SJ, Zauber AG, Fletcher RH, Stillman JS, O'Brien MJ, Levin B, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. CA Cancer J Clin. 2006;56(3):143–59. quiz 84-5.

    Article  PubMed  Google Scholar 

  37. Siegel JE, Weinstein MC, Russell LB, Gold MR. Recommendations for reporting cost-effectiveness analyses. Panel on Cost-Effectiveness in Health and Medicine. JAMA. 1996;276(16):1339–41.

    CAS  Google Scholar 

  38. Hirth RA, Chernew ME, Miller E, Fendrick AM, Weissert WG. Willingness to pay for a quality-adjusted life year: in search of a standard. Med Decis Making. 2000;20(3):332–42.

    Article  PubMed  CAS  Google Scholar 

  39. Braithwaite RS, Meltzer DO, King JT Jr, Leslie D, Roberts MS. What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule? Med Care. 2008;46(4):349–56.

    Article  PubMed  Google Scholar 

  40. Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG, Habbema JD, Kuipers EJ. Effect of rising chemotherapy costs on the cost savings of colorectal cancer screening. J Natl Cancer Inst. 2009;101(20):1412–22.

    Article  PubMed  Google Scholar 

  41. Ladabaum U, Song K. Projected national impact of colorectal cancer screening on clinical and economic outcomes and health services demand. Gastroenterology. 2005;129(4):1151–62.

    Article  PubMed  Google Scholar 

  42. Flottemesch T. C-A5-02: Is Tailored Screening for Colorectal Cancer based on Gender and Race Cost-Effective? Clin Med Res. 2011;9(3–4):174.

    Article  Google Scholar 

  43. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739–50.

    Article  PubMed  Google Scholar 

  44. Force USPST. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(9):627–37.

    Google Scholar 

  45. Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG, Boer R, Wilschut J, Winawer SJ, et al. Individualizing colonoscopy screening by sex and race. Gastrointest Endosc. 2009;70(1):96–108. e1-24.

    Article  PubMed  Google Scholar 

  46. Walter LC, Lewis CL, Barton MB. Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence. Am J Med. 2005;118(10):1078–86.

    Article  PubMed  Google Scholar 

  47. Eddy DM, Adler J, Patterson B, Lucas D, Smith KA, Morris M. Individualized guidelines: the potential for increasing quality and reducing costs. Ann Intern Med. 2011;154(9):627–34.

    PubMed  Google Scholar 

  48. Villavicencio RT, Rex DK. Colonic adenomas: prevalence and incidence rates, growth rates, and miss rates at colonoscopy. Semin Gastrointest Dis. 2000;11(4):185–93.

    PubMed  CAS  Google Scholar 

  49. Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol. 2001;96(10):2992–3003.

    Article  PubMed  CAS  Google Scholar 

  50. Cottet V, Pariente A, Nalet B, Lafon J, Milan C, Olschwang S, et al. Colonoscopic screening of first-degree relatives of patients with large adenomas: increased risk of colorectal tumors. Gastroenterology. 2007;133(4):1086–92.

    Article  PubMed  Google Scholar 

  51. Giovannucci E, Colditz GA, Stampfer MJ, Willett WC. Physical activity, obesity, and risk of colorectal adenoma in women (United States). Cancer Causes Control. 1996;7(2):253–63.

    Article  PubMed  CAS  Google Scholar 

  52. Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Physical activity, obesity, and risk for colon cancer and adenoma in men. Ann Intern Med. 1995;122(5):327–34.

    PubMed  CAS  Google Scholar 

  53. Elwing JE, Gao F, Davidson NO, Early DS. Type 2 diabetes mellitus: the impact on colorectal adenoma risk in women. Am J Gastroenterol. 2006;101(8):1866–71.

    Article  PubMed  Google Scholar 

  54. Wilson LS, Lightwood J. Model of estimated rates of colorectal cancer from polyp growth by year of surveillance. J Med Screen. 2001;8(4):187–96.

    Article  PubMed  CAS  Google Scholar 

  55. Butterly LF, Chase MP, Pohl H, Fiarman GS. Prevalence of clinically important histology in small adenomas. Clin Gastroenterol Hepatol. 2006;4(3):343–8.

    Article  PubMed  Google Scholar 

  56. O'Brien MJ, Winawer SJ, Zauber AG, Gottlieb LS, Sternberg SS, Diaz B, et al. The National Polyp Study. Patient and polyp characteristics associated with high-grade dysplasia in colorectal adenomas. Gastroenterology. 1990;98(2):371–9.

    PubMed  Google Scholar 

  57. Shinya H, Wolff WI. Morphology, anatomic distribution and cancer potential of colonic polyps. Ann Surg. 1979;190(6):679–83.

    Article  PubMed  CAS  Google Scholar 

  58. Scheiden R, Sand J, Pandin M, Wagener Y, Capesius C. Colorectal high-grade adenomas: incidence, localization and adenoma-adenocarcinoma ratio in a retrospective and comparative population-based study of 225 consecutive cases between 1988 and 1996. Int J Colorectal Dis. 2000;15(1):29–34.

    Article  PubMed  CAS  Google Scholar 

  59. Hermanek P KK. Illustrierte Synopsis kolorektaler Tumore. Pharmazeutische Verlagsanstalt, Munich. 1983.

  60. Hofstad B, Vatn M. Growth rate of colon polyps and cancer. Gastrointest Endosc Clin N Am. 1997;7(3):345–63.

    PubMed  CAS  Google Scholar 

  61. Stein KB, Snyder CF, Barone BB, Yeh HC, Peairs KS, Derr RL, et al. Colorectal Cancer Outcomes, Recurrence, and Complications in Persons With and Without Diabetes Mellitus: A Systematic Review and Meta-Analysis. Dig Dis Sci. 2009.

  62. Rex DK. Colonoscopy: a review of its yield for cancers and adenomas by indication. Am J Gastroenterol. 1995;90(3):353–65.

    PubMed  CAS  Google Scholar 

  63. Loeve F, Brown ML, Boer R, van Ballegooijen M, van Oortmarssen GJ, Habbema JD. Endoscopic colorectal cancer screening: a cost-saving analysis. J Natl Cancer Inst. 2000;92(7):557–63.

    Article  PubMed  CAS  Google Scholar 

  64. Warren JL, Klabunde CN, Mariotto AB, Meekins A, Topor M, Brown ML, et al. Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med. 2009;150(12):849–57. W152.

    PubMed  Google Scholar 

  65. Levin TR, Zhao W, Conell C, Seeff LC, Manninen DL, Shapiro JA, et al. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med. 2006;145(12):880–6.

    PubMed  Google Scholar 

  66. Ness RM, Holmes AM, Klein R, Dittus R. Utility valuations for outcome states of colorectal cancer. Am J Gastroenterol. 1999;94(6):1650–7.

    Article  PubMed  CAS  Google Scholar 

  67. Sullivan PW, Ghushchyan V. Preference-Based EQ-5D index scores for chronic conditions in the United States. Med Decis Making. 2006;26(4):410–20.

    Article  PubMed  Google Scholar 

  68. Sullivan PW, Ghushchyan V. Mapping the EQ-5D index from the SF-12: US general population preferences in a nationally representative sample. Med Decis Making. 2006;26(4):401–9.

    Article  PubMed  Google Scholar 

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Conflict of Interest Declaration

The authors declare no conflict of interest. This study was carried out by Archimedes in collaboration with Drs. Smith and Walter. Dr. Walter is supported by a grant 1R01CA134425 from the National Cancer Institute.

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Correspondence to Tuan A. Dinh PhD.

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Dinh, T.A., Alperin, P., Walter, L.C. et al. Impact of Comorbidity on Colorectal Cancer Screening Cost-Effectiveness Study in Diabetic Populations. J GEN INTERN MED 27, 730–738 (2012). https://doi.org/10.1007/s11606-011-1972-6

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  • DOI: https://doi.org/10.1007/s11606-011-1972-6

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