Cost-effectiveness of colonoscopy and related procedures: population screening perspectives

Abstract

Colorectal cancer (CRC) screening can reduce the incidence and mortality of CRC, and many countries with moderate-to-high incidences of CRC have implemented population screening programs. Colonoscopy plays a pivotal role in the context of CRC screening as the primary screening modality, the diagnostic exam after a positive noninvasive test, the therapeutic procedure for resecting detected neoplasms, and the surveillance exam after the removal of neoplastic lesions. Although colonoscopy outperforms other noninvasive tests in detecting colorectal neoplasms, it is associated with higher cost, manpower, and invasiveness. Owing to the heterogeneity of healthcare systems in terms of the scale of health revenue, population demographics, and the payment systems in each country, the optimal or most cost-effective screening strategy may vary. Accordingly, economic appraisal of different approaches is essential, especially in organized screening programs within which the resources and the clinical capacity are constrained, and each step of the screening flow needs careful monitoring. The therapeutic procedures applied to manage screening-detected lesions and subsequent surveillance procedures also contribute to substantial additional costs. The level of willingness to pay is affected by various factors, including demographics, income, educational level, and health consciousness, and largely affects the optimal strategies. Herein, we systematically review and summarize the current evidence regarding the cost-effectiveness of colonoscopic screening, related therapeutic procedures, and subsequent surveillance and provide a balanced view from the perspective of population screening programs. It was revealed that 10-year colonoscopy is the most effective strategy compared to other strategies under the higher willingness-to-pay threshold or low colonoscopy cost. There are, however, discrepancies in the results among studies from different countries, which could be associated with the different cost parameters and assumptions used in the models. As for various therapeutic procedures for colorectal neoplasms such as polypectomy, endoscopic mucosal resection, or endoscopic submucosal dissection, strategies based on the risk of advanced histology or deep submucosal invasion based on image-enhanced endoscopy are the least expensive and avoid more recurrences. Furthermore, subsequent surveillance strategies that are based on the risk of CRC are more cost-effective. This article provides a comprehensive review of the literatures and a balanced view from the perspective of population screening programs.

Keywords

Colonoscopy / cost-effectiveness / colorectal cancer screening / surveillance / polypectomy / endoscopic mucosal resection / endoscopic submucosal dissection

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