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

44 Screening for Colorectal Cancer KCE reports vol.45
using the health insurer perspective. Using U.S. population estimates, 22 million
would be eligible for family history assessment, and one million would be eligible
for early colonoscopy; 2.834 invasive cancers would be detected, and 29.331 life
years would be gained. The initial program cost would be USD $900 million.
The discounted cost per life year gained of family history assessment versus no
assessment equals USD $58.228. The results were most sensitive to the
estimates of life expectancy benefit from earlier screening, the cost of
colonoscopy, and the relative risk of colon cancer in those with a family history.
The authors concluded that the cost-effectiveness of family history assessment
for colorectal cancer approaches that of other widely accepted technologies;
yet, the results are sensitive to several assumptions where better data are
needed. Because of the relatively high prevalence of family history in the
population, careful analysis and empirical data are needed.
3.3.6 Conclusion
Individuals with a family history of colorectal cancer are at increased risk of
developing colorectal cancer and warant colonoscopic surveillance starting
before 50 years of age. This risk is greater (and the targeted screening should
start earlier) when associated with early age of onset or multiple affected
relatives.
3.4 RISK STRATIFICATION
The American Gastroenterological Association (AGA) recommends 55 that
clinicians determine an individual patient s risk status for the development of
CRC well before the earliest potential initiation of screening (typically around
age 20 years, but earlier if there is a family history of FAP). The individual s risk
status determines when screening should be initiated and what tests and
frequency are appropriate. Risk stratification can be accomplished by asking
several questions aimed at uncovering the risk factors for colorectal cancer 28:
(1) Has the patient had colorectal cancer or an adenomatous polyp and at what
age? (2) Does the patient have an illness (e.g., inflammatory bowel disease) that
predisposes him or her to colorectal cancer? (3) Has a family member had
colorectal cancer or an adenomatous polyp? If so, how many, was it a firstdegree
relative (parent, sibling, or child), and at what age was the cancer or
polyp first diagnosed? A positive response to any of these questions should
prompt further efforts to identify and define the specific condition associated
with increased risk.
For patients with a positive family history the New Zealand Guidelines Group
(NZGG) proposes a risk stratification in 3 categories 27, taking however 55 years
as cut-off age instead of the 60 years used in the US:
1. Category 1: Individuals with a slight increase in risk of CRC
due to family history (up to 2-fold compared with the general
population): one FDR with CRC diagnosed over the age of 55
years.
2. Category 2: Individuals with a moderate increase in risk of
CRC (3-to 6-fold compared with the general population):
a. One FDR with CRC diagnosed under the age of 55
years.
b. Two FDR on the same side of the family with CRC
diagnosed at any age.