• Marjolein J E Greuter, Clasine M de Klerk, Gerrit A Meijer, Evelien Dekker, and CoupéVeerle M HVMHFrom VU University Medical Center, Academic Medical Center, and Netherlands Cancer Institute, Amsterdam, the Netherlands..
• From VU University Medical Center, Academic Medical Center, and Netherlands Cancer Institute, Amsterdam, the Netherlands.
• Ann. Intern. Med. 2017 Oct 17; 167 (8): 544-554.

BackgroundPopulation-based screening to prevent colorectal cancer (CRC) death is effective, but the effectiveness of postpolypectomy surveillance is unclear.ObjectiveTo evaluate the additional benefit in terms of cost-effectiveness of colonoscopy surveillance in a screening setting.DesignMicrosimulation using the ASCCA (Adenoma and Serrated pathway to Colorectal CAncer) model.Data SourcesDutch CRC screening program and published literature.Target PopulationAsymptomatic persons aged 55 to 75 years without a prior CRC diagnosis.Time HorizonLifetime.PerspectiveHealth care payer.InterventionFecal immunochemical test (FIT) screening with colonoscopy surveillance performed according to the Dutch guideline was simulated. The comparator was no screening or surveillance. FIT screening without colonoscopy surveillance and the effect of extending surveillance intervals were also evaluated.Outcome MeasuresCRC burden, colonoscopy demand, life-years, and costs.Results Of Base Case AnalysisFIT screening without surveillance reduced CRC mortality by 50.4% compared with no screening or surveillance. Adding surveillance to FIT screening reduced mortality by an additional 1.7% to 52.1% but increased lifetime colonoscopy demand by 62% (from 335 to 543 colonoscopies per 1000 persons) at an additional cost of €68 000, for an increase of 0.9 life-year. Extending the surveillance intervals to 5 years reduced CRC mortality by 51.8% and increased colonoscopy demand by 42.7% compared with FIT screening without surveillance. In an incremental analysis, incremental cost-effectiveness ratios (ICERs) for screening plus surveillance exceeded the Dutch willingness-to-pay threshold of €36 602 per life-year gained.Results Of Sensitivity AnalysisWhen using a parameter set representing low colorectal lesion prevalence or when colonoscopy costs were halved or colorectal lesion incidence was doubled, screening plus surveillance became cost-effective compared with screening without surveillance.LimitationLimited data on FIT performance and background CRC risk in the surveillance population.ConclusionAdding surveillance to FIT screening is not cost-effective based on the Dutch ICER threshold and substantially increases colonoscopy demand. Extending surveillance intervals to 5 years would decrease colonoscopy demand without substantial loss of effectiveness.Primary Funding SourceAlpe d'HuZes, Dutch Cancer Society, and Stand Up To Cancer.

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