■结直肠癌(CRC)筛查已被证明是有效且节省成本的。然而,早发性CRC发病率上升的趋势对德国目前仅针对50岁以上人群的国家筛查计划提出了挑战,将筛查延长到45-49年可能是合理的。本研究旨在评估从德国45年开始的CRC筛查策略的成本效益。
■DECAS,一个个体水平的模拟模型,考虑了腺瘤和锯齿状的CRC发展途径,并通过德国CRC流行病学和筛查效果进行了验证。用于成本效益分析。从45岁开始的四种CRC筛查策略,包括10年一次的结肠镜检查(COL),每年/两年一次的粪便免疫化学试验(FIT),或者两者的结合,与德国从50岁开始的当前筛查相比。考虑了三种依从性情况:完美的依从性,当前的坚持,和高筛查依从性。对于每个策略,我们模拟了从20岁到90岁或死亡的100,000名平均CRC风险个体的队列.结果包括避免的CRC病例,防止死亡,质量调整寿命年(QALYG),以及考虑CRC治疗和筛查成本的总增量成本。采用3%的折现率,成本在2023年为欧元。
■在45岁时启动10年一次结肠镜检查或FIT+COL组合策略,导致7-28个QALY的增量增加,每1000个人的增量成本为28,360-71,759欧元,与目前的战略相比。ICER从每个QALYG的1,029欧元到9,763欧元不等,结肠镜检查所需的额外人数为129~885/1,000例.在替代方案中,从45岁开始的三次结肠镜检查策略被证明是最有效的,而仅FIT战略由目前实施的战略主导。在概率敏感性分析中,研究结果保持一致。
■成本效益研究结果支持在45岁时通过单独结肠镜检查或联合FIT进行CRC筛查,在成本适度增加的情况下,质量调整后的寿命年大幅增加。我们的研究结果强调了比目前的做法提前5年实施CRC筛查以实现更显著的健康和经济效益的重要性。
Colorectal cancer (CRC) screening has been shown to be effective and cost-saving. However, the trend of rising incidence of early-onset CRC challenges the current national screening program solely for people ≥50 years in Germany, where extending the screening to those 45-49 years might be justified. This study aims to evaluate the cost-effectiveness of CRC screening strategies starting at 45 years in Germany.
DECAS, an individual-level simulation model accounting for both adenoma and serrated pathways of CRC development and validated with German CRC epidemiology and screening effects, was used for the cost-effectiveness analysis. Four CRC screening strategies starting at age 45, including 10-yearly colonoscopy (COL), annual/biennial fecal immunochemical test (FIT), or the combination of the two, were compared with the current screening offer starting at age 50 years in Germany. Three adherence scenarios were considered: perfect adherence, current adherence, and high screening adherence. For each strategy, a cohort of 100,000 individuals with average CRC risk was simulated from age 20 until 90 or death. Outcomes included CRC cases averted, prevented death, quality-adjusted life-years gained (QALYG), and total incremental costs considering both CRC treatment and screening costs. A 3% discount rate was applied and costs were in 2023 Euro.
Initiating 10-yearly colonoscopy-only or combined FIT + COL strategies at age 45 resulted in incremental gains of 7-28 QALYs with incremental costs of €28,360-€71,759 per 1,000 individuals, compared to the current strategy. The ICER varied from €1,029 to €9,763 per QALYG, and the additional number needed for colonoscopy ranged from 129 to 885 per 1,000 individuals. Among the alternatives, a three times colonoscopy strategy starting at 45 years of age proves to be the most effective, while the FIT-only strategy was dominated by the currently implemented strategy. The findings remained consistent across probabilistic sensitivity analyses.
The cost-effectiveness findings support initiating CRC screening at age 45 with either colonoscopy alone or combined with FIT, demonstrating substantial gains in quality-adjusted life-years with a modest increase in costs. Our findings emphasize the importance of implementing CRC screening 5 years earlier than the current practice to achieve more significant health and economic benefits.