Report in English with a Dutch summary (KCE reports 45A)

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108 Screening for Colorectal Cancer KCE reports vol.45 included. Only two studies incorporated indirect costs. From the studies comparing no screening with FOBT screening, only Gyrd-Hansen 491, 493 analysed the influence of including production losses. Maciosek 507, who estimated the average value of offering patients a choice of screening tools, adjusted cost estimates to reflect the cost of patient time for screening and follow-up. 6.3.1.3 Time window 6.3.1.4 Currencies Health interventions, and especially screening campaigns, produce most of the costs immediately or in the very short term, whereas health benefits and/or cost savings accumulate over a far longer period. Evaluating the costs and effects of screening programs over a short period would only underestimate the cost effectiveness of the program, making it apparently less favourable. As a result, costs and effects incurred by screening programs should be calculated over the long term. The studies analysing FOBT screening are based on long term follow up data from RCTs with a long follow-up. All but one, i.e. the study of Helm 494 which was based on 10-year follow-up data, used modelling techniques to simulate results further in the future up to end of life. From the other non-RCT-based studies, all but one developed models with a timeframe of 20 years up to lifetime. Only O Leary 500 applied a 10-year timeframe. For practical reasons all costs will also be presented in Euro, next to the original currency. Exchange rates used are those of October 26 th, 2006 (table 27). Table 27: Exchange rates (October 26 th, 2006) 1,00 USD (United States Dollars) 0,789804 EUR 1,00 GBP (United Kingdom Pounds) 1,48812 EUR 1,00 CAD (Canadian Dollars) 0,703149 EUR 1,00 AUD (Australian Dollars) 0,602639 EUR 1,00 DKK (Dannish Kroner) 0,134155 EUR 1,00 ILS (Israel New Shekels) 0,184473 EUR 1,00 SGD (Singapore Dollars) 0,503717 EUR (October 30 th) 6.3.2 Interventions and comparisons For our overview, the cost effectiveness studies have been divided into three categories, i.e. studies comparing FOBT with no screening, studies looking at guaiac-based FOBT versus immunochemical FOBT, and studies taking into account colonoscopy. Since this overview is about mass screening for a population at average risk, the study on family history assessment 111 will not be considered in this chapter. 6.3.2.1 FOBT compared with no screening Intervention and population The studies comparing FOBT with no screening are the following: Whynes et al. 489, 490, Gyrd-Hansen et al. 491, 493, Helm et al. 494, Flanagan et al. 498, Whynes 501, Stone et al. 502, Lejeune et al. 504. Table A 4.1 provides an overview of these studies. Whynes and Gyrd-Hansen both have two separate published studies
KCE reports vol.45 Screening for Colorectal Cancer 109 which were based on the same methodology and data. Therefore, we considered these studies as a single study. The core scenario in all studies was characterized by biennial screening, i.e. subjects completing the initial screen, and for whom no abnormalities had been detected, were offered a re-screen after two years. Most of the studies also analysed annual screening either in their base case scenario or as part of a sensitivity analysis. 491, 489, 493, 490, 494, 498 One study even included screening intervals of 1,5 and 3 years since it considered that specific outcomes of the Danish RCT could be generalized to screening programs with alternative screening intervals within a range of 2 years +1 year (Gyrd-Hansen). Participants with positive test results were further investigated by colonoscopy or in some studies by DCBE (Gyrd-Hansen, Helm) where colonoscopy failed or was not acceptable. After a negative colonoscopy, participants would not be invited for screening for a period of 10 years, provided no polyps were found (Flanagan). The target population exists primarily of individuals aged between 50 and 74 years.(Whynes, 1998, 1999; Gyrd-Hansen, 1998, 1999; Flanagan, 2003; Lejeune, 2004), while a few studies also include younger patients (starting at 45 years)(Helm, 2000; Whynes, 2004). Gyrd-Hansen (1998, 1999) and Stone questioned the optimal target population by performing subgroup analyses for different target populations. Cost items Costs may vary widely over the several studies due to country differences, year of pricing, items included, etc. Therefore it is important to mention which costs have been included and their price. All studies of course include the cost of FOBT and, for positive FOBTs, the costs for colonoscopy. FOBT costs lie within the range of 3,3 and 9,8 with two exceptions of 16,5 and 24,6 due to the inclusion of GP visits costs h . For colonoscopy, the difference is even more noticeable ( 130 - 995) i . Several studies also included costs produced by follow-up investigations. This follow-up program was assumed to consist of colonoscopy every three years after finding a polyp (Gyrd-Hansen, 1998, 1999; Helm). In the Canadian study, follow-up colonoscopies are performed at three, five, and 10-year intervals if polyps were found (Flanagan). The Australian and French studies include an additional expense from increased follow-up activities which amount to respectively 528 and 843 over a 5-year period. The costs for setting up a national screening campaign should also be taken into account. Gyrd-Hansen and colleagues (1998) mention a fixed cost per year of 27.144, j based on the average yearly costs incurred over the initial 8 years of the Funen-1 trial in which 30.967 persons were offered screening. Costs of coordinator and secretaries were assumed to vary with number of invited h 9DKK + 11,5DKK + 8DKK = 3,71 (for respectively FOBT cost, mailing and test analysis) (Gyrd-Hansen); 10$ = 7,9 (Helm); CAD4,65 9,30 and CAD6 - 8 = 7,5 12,1 = 9,8 on average (for resp. the test kit and processing) (Flanagan); £3,29 = 4,9 (test kit, administration, return postage) (Whynes, 2004); AUD41 = 24,6 (test kit, transport, processing and GP visit) (Stone, 2004); 12.52 (test, GP and mailing) and 4 (test analysis) = 16,52 (Lejeune, 2004). i 1000DKK = 130 (Gyrd-Hansen); $1260 = 995 (Helm); CAD350 - 425 = 245 - 298 (Flanagan); £187 = 279 (Whynes, 2004); AUD1000 = 600 (Stone, 2004); 526 (Lejeune, 2004). j Computer assistant 16.800DKK, software 150.000DKK, offices 36.000DKK and inventory 6000DKK (208.800DKK = 27.144). It is assumed that costs of software, offices and inventory are independent of the size of the program.(Gyrd-Hansen, 1998, 1999)
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KCE reports 1. Effectiviteit en kos
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