gms | German Medical Science

Introduction: In Germany, the organized colorectal cancer (CRC) screening program includes colonoscopy or immunologic fecal blood testing (iFOBT) for individuals as of age 50. However, individuals with familial CRC risk may benefit from screening at younger age. Our aim was to systematically evaluate and compare the long-term benefit-harm balance and cost effectiveness of different screening strategies for individuals younger than age 50 identified with familial CRC risk in Germany.

Methods: We developed and validated a Markov-state-transition model simulating CRC progression and management for individuals in Germany identified with familial CRC risk. The model was applied to evaluate various screening strategies that differ by screening test (colonoscopy or iFOBT), age at start (30, 35, 40, 45, 50 or 55 years) and end of screening (65, 70 or 75 years), screening interval (iFOBT: annual or biennial; colonoscopy: every 10 years), and follow-up algorithms for the German health care context. We used German clinical, epidemiological data and economic data (index year 2020) along with published international test accuracy data from meta-analyses. We applied a lifelong time horizon and adopted the perspective of the German statutory health insurance. Effects and costs were discounted at 3% per year. Evaluated outcomes included health benefits (CRC-related deaths avoided, life-years gained [LYG]), potential harms (additional colonoscopies), incremental harm-benefit ratios (IHBR), and incremental cost-effectiveness ratios (ICER; in Euro per LYG), compared to the next non-dominated strategy. Comprehensive sensitivity analyses were performed to assess uncertainty.

Results: In the base-case analysis with full participation, both benefits and harms increased with lower age for screening start and shorter intervals.

The IHBRs for 10-yearly colonoscopy expressed as additional colonoscopies/LYG were 3.7 (age 55-65 vs. no screening) and 9.9 (age 45-65 years), 14.6 (age 35-65 years) and 28.9 (age 30-70 years) compared to the next non-dominated strategy. Corresponding IHBRs for iFOBT screening were 1.3 (biennial, age 45-65 years vs. no screening) and 3.5 (biennial, age 35-65 years), 6.0 (biennial, age 30-70 years) and 33.8 (annual, age 30-54 years; biennial, age 55-75 years) compared to the next non-dominated strategy.

Compared to current screening standard starting at age 50, 10-yearly colonoscopy age 45-65 was cost saving. Ten-yearly colonoscopy with an earlier start and longer screening periods yielded ICERs of 2,962, 3,240 and 9,279 Euro/LYG for screening periods from 40-70, 35-65, and 30-70, respectively. Compared to current screening standard, biennial iFOBT age 35-75 was cost saving. The next more effective iFOBT strategies yielded ICERs of 2,630 Euro/LYG (biennial, age 30-70), and 34,675 Euro/LYG (annual, age 30-54; biennial, age 55-75), respectively.

Discussion/conclusion: Based on our decision-analytic results, offering colonoscopy or iFOBT screening to individuals younger than 50 years identified with familial CRC risk may be beneficial and cost-effective in the German health care setting. Depending on the acceptance for additional harms per additional unit of benefit, 10-yearly colonoscopy or alternatively biennial iFOBT from age 30 to 70 may be recommended for individuals with familial CRC. Future research is needed to acquire evidence-based information on the impact of screening on health-related quality-of-life.

This work was supported by Funded by GB-A Innovationsfonds Grant: 01NVF17026. The funding agreement ensured the authors’ independence in designing the study, analyzing and interpreting the data, writing, and publishing the report.

The authors declare that a positive ethics committee vote has been obtained.

This contribution has already been published:

1.

14th Annual Meeting of the German Society for Health Economics (DGGÖ-Deutsche Gesellschaft für Gesundheitsökonomie); 2022 March 28.-29. 2022; Hamburg, Germany.

2.

Annual Meeting of the Professional Society for Health Economics and Outcomes Research (ISPOR) Washington D. C., USA (and Virtual) May 15-18 2022;

3.

Biannual Meeting of the European Health Economics Association (EUHEA), 5-7 July, Oslo