Stratified Assessment And Cost-effectiveness Analysis Of Simplified Colorectal Cancer Screening Protocol

Background:Colorectal cancer(CRC)is the third most common malignant neoplasm worldwide and the third leading cause of cancer deaths in the United States.According to the International Agency for Research on Cancer(IARC),there are about 1,360,600 new cases of colorectal cancer and about 693,900 deaths worldwide.In recent years,the incidence and mortality of colorectal cancer have been rapidly increased with the aggravating trend of aging population and the gradual change of lif’estyle and diet in China.And the cancer spectrum in China is becoming similar to that in Western developed countries.Several randomized trials(RCTs)have demonstrated that screening effectively reduces CRC morbidity and mortality,but no single colorectal cancer(CRC)screening protocol has been determined to be applicable worldwide.In China,a CRC screening protocol that combines double fecal immunochemical tests(FITs)and a high-risk factor questionnaire(HRFQ)as the first stage of screening and colonoscopy as the second stage of screening was adapted by the Chinese Ministry of Health in 2006.However,applying this screening protocol nationally remains difficult because its effectiveness and convenience are controversial.so a more detailed and accurate evaluation is needed.This study intends to use epidemiological methods to evaluate and analyze the cost effectiveness and screening effects of items of the CRC screening protocol in China.Methods:This study was based on the results of colorectal cancer screening program(scenario A,control)conducted in Jiashan County,China from 2007 to 2012.Scenario A was divided into scenarios B-G(by selecting some items at the first stage of screening).And 6 new simplification schemes were created to further verify the role of each part.And these scenarios were used to analyze the detection rates of CRC and advanced adenoma as well as the cost-effectiveness of the protocol.In addition,this study will also analyze the effects of the screening program on the incidence and deaths of colorectal cancer in Jiashan county.Results:The crude CRC morbidity and mortality in Jiashan county were both higher than the national average.Except for the incidence of CRC significantly increased in the year of screening,there was no significant difference in CRC morbidity and mortality shortly after screening compared with that before screening.Scenario G(removing FITs)reduced the detected cases of CRC,adenoma,and advanced adenoma by 70.1%,53.9%and 60.7%,respectively,and the costs per cases of CRC and advanced adenoma were 60%and 19%higher than those in Scenario A,respectively.Scenario F(removing the whole HRFQ)reduced the high-risk population by nearly 50%,as well as the detected cases of CRC and advanced adenoma by 7.3%and 28.1%,whereas the whole HRFQ accounted for 9.5%of the total screening cost and the costs per cases of CRC and advanced adenoma were reduced by 37%and 19%,respectively,compared with scenario A.In scenarios B-E(deleting some high-risk factor questions on the HRFQ),the odds ratios(ORs)of the detection rates of CRC,adenoma and advanced adenoma were near 1.00,except for the detection rates of adenoma and advanced adenoma increased by 11%and 17%,respectively,in scenario B.Scenarios C and D reduced the high-risk population by 4.8%and 3.0%,as well as the total screening costs by 3.4%and 9.6%,respectively.Scenarios B and E(both included the FITs and a personal history of cancer or colorectal adenoma)reduced the high-risk population by 21.1%and 14.6%and the total screening costs by 14.4%and 9.6%,respectively,while the detected cases of CRC and advanced adenoma decreased by only 3%and 10%,respectively.In scenario B,the costs per case of CRC and advanced adenoma were 12%and 6%lower than those in scenario A,respectively,and scenario E reduced the cost per case of CRC by 7%.Simplified scenarios B+C,B+D,B+E,C+E and D+E reduced the total costs by 18.7,16.4,25.7,13.5 and 11.3%,respectively.Scenario B+C,B+D and B+E reduced the cost per case of CRC by 16%,14%and 21%,respectively,and the detection rates of CRC increased by 33%,31%and 54%,respectively.Conclusion:The results of this study demonstrate that FITs and a personal history(including cancer and colorectal adenoma)in the first stage of screening have the highest screening effect and cost-effectiveness.