Can Colonoscopy Remain Cost-Effective for Colorectal Cancer Screening? The Impact of Practice Patterns and the Will Rogers Phenomenon on Costs

OBJECTIVES: The adenoma detection rate (ADR) in screening colonoscopy is higher than original cost-effectiveness models estimated. Future colorectal cancer (CRC) risk is decreased once the ADR is 20%, but it is unclear how much additional protection is provided with higher ADRs. We modeled the impact of a high ADR on future CRC risk and surveillance colonoscopy burden. METHODS: We created three hypothetical scenarios for 100,000 average-risk individuals undergoing screening colonoscopy at age 50: (i) 20% ADR with 30% future CRC risk reduction; (ii) 50% ADR with 30% future CRC risk reduction; and (iii) 50% ADR with 50% future CRC risk reduction. After colonoscopy, patients could have high-risk or low-risk adenomas, or no adenomas. RESULTS: When the ADR increases from 20% to 50% but no additional CRC cases are prevented, future CRC risk for each group is still reduced, because lower-risk patients migrate into apparently higher-risk groups (the Will Rogers phenomenon). Future risk is further reduced if a 50% ADR leads to greater protection from CRC. However, despite the reductions in group-specific and overall future CRC risk, 34,635 additional surveillance colonoscopies are performed before the cohort is 60 years old when the ADR is 50% compared with 20%. CONCLUSIONS: If current surveillance practices continue along with high ADRs, screening colonoscopy may not remain cost-effective. Am J Gastroenterol 2013;108:296-301; doi:10.1038/ajg.2012.195