Download Dr. Terri Green

Colorectal Cancer Screening
- Economic Considerations
Terri Green
University of Canterbury
Presentation for “Future of Cancer Screening in New Zealand”.
Auckland, 7 August 2015
Economic considerations
• Is it value for money? (Yes, potentially)
– What are the benefits?
– What are the costs?
• Can we achieve the benefits?
• Can we afford it?
• Are there alternatives?
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Figure 1. FOBT Screening diagram –
patient flows
Cancer
Invite
FOBT
-ve
Invite
rescreen
2 years
Invite
Rescreen
5 years
+ve
Refer
colonoscopy
No cancer
or adenoma
Colonoscopy
Small
Polyp
<10mm
Treatment
Large
Polyp
>10mm
Surveillance
colonoscopy
3 and 6 years
Surveillance
colonoscopy
5 years
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Fig 3. Biennial FOBTi screening, 50-74 years:
Referral and Surveillance colonoscopy 2011-2031
(Participation 60%, Positivity 6.4%, 4.8%)
Green, Richardson and Parry (NZMJ, 2012)
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Can we do it?
• 18000 colonoscopies rising to 28000
• Assumes
– Participation 60%
Compared to 55% for pilot
– Positivity 6.4% for initial screen
– 4.8% for later screens
Compared to 7.5% for pilot
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What is the cost of Programme?
-estimated at $39 M per year* (Sapere, 2015)
(Steady state cost; initial years more costly)
Key Determinants of cost:
• Participation rate in screening (pilot, 55%)
• Positivity rate (pilot, 7.5%)
• How programme is delivered:
– Use of private sector for colonoscopies
– Regional variations
(*Range $26M-$50M, Sapere report MOH 2015)
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Can we afford “it”?
• Depends on other demands on public
money ……
(Annual CRC treatment costs approx $83M*.)
• If it can be delivered it is worthy of
consideration
• Are there alternatives to address Bowel
cancer? E.G. screening by once only
Flexible Sigmoidoscopy.
(*Sheerin, Green, Sarfati, Cox, NZMJ 2015)
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Approx Comparison: Annual volumes
FOBTi and Flexible Sigmoidoscopy
(60% participation)
FOBTi
(50-74, every 2 years)
Flex sig
(one-off, age 55)
• 618,000 target
• 371,000 screens
• 18,000
colonoscopies
• 60,000 target
• 36,000 screens
• 1800*
colonoscopies
(* 5%, Atkins, Lancet, 2010) 8
Balancing costs and benefits:
- FOBTi , compared to Flex sig
•
•
•
•
•
•
Greater Reduction in CRC incidence√
Greater Reduction in mortality √
Higher cost
Lower cost per QALY √
More adverse events
Higher colonoscopy load
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