1. Evaluating options for a colorectal cancer screening programme in Ireland
Sharp L, Tilson L, Whyte S, Ó Céilleachair A*, Walsh C, Usher C, Tappenden P, Chilcott J, Staines A, Barry M & Comber H.
Population-based cancer research in Ireland, Davenport Hotel September 4th 2009

2. Background
Over 2,000 new cases of colorectal cancer (CRC) are diagnosed in the Republic of Ireland each year.
2nd most common cancer for both genders
Over 900 deaths per annum from CRC
On most key indicators Irish people fare worse than their European contemporaries
Higher incidence rates
Lower survival rates
Higher mortality amongst men
As population ages incidence is projected to increase

3. Opportunity for Screening
If caught early, CRC is very treatable
Survival much higher in Stage I-II disease
Screening in place for many European countries
Numerous modalities exist for early detection of CRC:
Guaic-based occult blood tests (gFOBT)
Immunochemical-based stool tests (FIT)
Flexible sigmoidoscopy

4. Cost-effectiveness analysis
Comparing the cost-effectiveness of two policies, A and B:
ICER = cost A – cost B/effect A – effect B
Effects may be in life-years gained (LYG) or quality-adjusted life years gained (QALYs)
The lower the ICER the “more” cost-effective A compared to B
€45,000 per QALY is an informal threshold of “cost-effectiveness” in an Irish setting

5. Evaluating Screening Options
Health technology assessment commissioned by HIQA
Evaluate using cost-effectiveness analysis competing alternative strategies for CRC screening in Ireland
Versus “No Screening” and also incrementally against each other
Estimate the likely resource burden of screening for a range of key services and also health outcomes over a ten year time horizon after the introduction of screening.

6. Methods
Core screening scenarios agreed with HIQA Expert Advisory Group:
biennial FIT at ages 55-74
biennial gFOBT at ages 55-74, with reflex FIT
FSIG once only at age 60
Supplementary scenarios also considered
Diagnostic investigations for postive screen test: colonoscopy or CT colonography
Surveillance for those with adenoma(s) ≥1cm removed: following current consensus recommendations (Atkins & Saunders, 2002)

7. Model
Markov model adapted from an existing model developed by collaborators in ScHARR
Natural history model of CRC
Hypothetical cohort of 55 year-olds tracked over their lifetime used for cost-effectiveness
Screening scenarios were then superimposed on this model
Outcome measures: Cost per QALY and cost per Life Year Gained (LYG)
Alternatives compared to “No Screening” and each other
Costs and outcomes 4%
Healthcare payer perspective

8. Data
Model parameters
Natural history data
Data on the performance of tests
Cost data
Other data such as uptake
Data sourced from extensive literature reviews, information from existing screening programmes and expert opinion
Sensitivity analysis
One/multi way
Probabilistic sensitivity analysis

9. Performance and Uptake
Parameter
Base-case
Range
FIT sensitivity
adenomas
cancers
gFOBT sensitivity
FSIG sensitivity
Test uptake/compliance
FIT uptake
gFOBT uptake
FSIG uptake
21%
71%
11%
36%
65% (low-risk)
74% (int/high-risk)
90%
53%
39%
19% - 22%
67% - 75%
10% - 12%
31% - 42%
60% - 70%
68% - 78%
85% - 95%
32% - 59%
24% - 67%
COL compliance
86%
81% - 90%

10. Costs Parameter Base-case Range Screening tests FIT kit
FIT processing and analysis
gFOBT kit
gFOBT processing and analysis
FSIG
Lifetime costs of managing symptomatic CRC
stage I
stage II
stage III
stage IV
€3.75
€11.60
€1.70
€7.81
€150
€23,688
€37,180
€48,835
€36,602
€ €4.50
€ €13.92
€ €2.04
€ €9.37
€120 - €180
€18,950 – €28,425
€29,744 - €44,616
€39,068 - €58,602
€29,281 - €43,922

11. Incremental Cost Effectiveness vs. “No Screening”
Scenario
Cost of screening & CRC management
Incremental
cost per person1
Expected QALYs per person
Incremental QALY per person1
ICER -Incremental cost per QALY gained
No screening
€ 1074 -
10.96
gFOBT at
55-74 years
€ 1107
€ 33.63
10.97
0.0076
€ 4,4282
FIT at years
€ 1114
€ 40.17
10.98
0.0237
€ 1,696
FSIG once at 60 years
€ 1077
€ 3.43
0.0058
€ 589
Costs and outcomes discounted at 4%
1 Each incremental value compares value for that strategy to common baseline of no screening
2 gFOBT considered dominated by a combination of FIT and FSIG

12. Cost-Effectiveness Plane

13. CE Plane: Extended Dominance

14. % reduction in CRC incidence rate2 % reduction in CRC mortality rate2
Health Outcomes
Scenario
% reduction in CRC incidence rate2
% reduction in CRC mortality rate2
gFOBT at years
1.0%
11.8%
FIT at years
14.7%
36.0%
FSIG once at 60 years
4.9%
7.5%

15. Health Outcomes
Higher proportion of screen-detected with FIT (30% of all cancers, vs 14% with gFOBT and 3% with FSIG)
Under all scenarios, screen-detected cancers have more favourable stage distribution than those detected symptomatically/clinically
Sensitivity analysis found analysis to be robust. Findings did not change when using LYG as outcome measure

16. FSIG v FIT

17. But… Lifetime1 Rates per 100,00 Complications3 Scenario FSIG2
Colonoscopy2
Polypectomy2
Major bleeding4
Bowel perforation
Death from perf
FIT -
34,632
9,486
132 57
3.00
gFOBT
3,386
1,215 12 5
0.26
FSIG
40,177
2,543
2,487 22
0.25
FIT=faecal immunochemical test; FSIG= flexible sigmoidoscopy; gFOBT=guaiac-based faecal occult blood test
1 Over the entire lifetime of the cohort, therefore for gFOBT and FIT includes 10 screening rounds
2 Related to screening, diagnosis or surveillance
3 Complications associated with diagnostic and surveillance colonoscopy and, where relevant, FSIG
4 Major abdominal bleeding, requiring admission or intervention

18. Conclusions
Compared to “No Screening” all of the options considered could be termed highly cost-effective.
Biennial FIT optimal strategy as it provides greater health gains at an acceptable ICER
Not insignificant resource considerations and complications need to be borne in mind

19. Thank You