Cost-effectiveness of colorectal cancer screening with computed tomography colonography - The impact of not reporting diminutive lesions

BACKGROUND. Prior cost-effectiveness models analyzing computed tomography colonography (CTC) screening have assumed that patients with diminutive lesions (<= 5 mm) will be referred to optical colonoscopy (OC) for polypectomy. However, consensus guidelines for CTC recommend reporting only polyps measuring >= 6 mm. The purpose of the current study was to assess the potential harms, benefits, and cost-effectiveness of CTC screening without the reporting of diminutive lesions compared with other screening strategies. METHODS. The cost-effectiveness of screening with CTC (with and without a 6-mm reporting threshold), OC, and flexible sigmoidoscopy (FS) were evaluated using a Markov model applied to a hypothetical cohort of 100,000 persons age 50 years. RESULTS. The model predicted an overall cost per life-year gained relative to no screening of $4361, $7138, $7407, and $9180, respectively, for CTC with a 6-mm reporting threshold, CTC with no threshold, FS, and OC. The incremental costs associated with reporting diminutive lesions at the time of CTC amounted to $118,440 per additional life-year gained, whereas the incidence of colorectal cancer was reduced by only 1.3% (from 36.5% to 37.8%). Compared with primary OC screening, CTC with a 6-mm threshold resulted in a 77.6% reduction in invasive endoscopic procedures (39,374 compared with 175,911) and 1112 fewer reported OC-related complications from perforation or bleeding. CONCLUSIONS. CTC with nonreporting of diminutive lesions was found to be the most cost-effective and safest screening option evaluated, thereby providing further support for this approach. Overall, the removal of diminutive lesions appears to carry an unjustified burden of costs and complications relative to the minimal gain in clinical efficacy.