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Cost-effectiveness of computerized tomographic colonography versus colonoscopy for colorectal cancer screening

From the Department of Medicine (Heitman, Manns, Hilsden, Romagnuolo); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Manns, Hilsden, Fong, Dean, Romagnuolo); and the Department of Medicine, Medical University of South Carolina, Charleston, SC (Romagnuolo)

Background: Computerized tomographic (CT) colonography is a potential alternative to colonoscopy for colorectal cancer screening. Its main advantage, a better safety profile, may be offset by its limitations: lower sensitivity, need for colonoscopy in cases where results are positive, and expense.

Methods: We performed an economic evaluation, using decision analysis, to compare CT colonography with colonoscopy for colorectal cancer screening in patients over 50 years of age. Three-year outcomes included number of colonoscopies, perforations and adenomas removed; deaths from perforation and from colorectal cancer from missed adenomas; and direct health care costs. The expected prevalence of adenomas, test performance characteristics of CT colonography and colonoscopy, and probability of colonoscopy complications and cancer from missed adenomas were derived from the literature. Costs were determined in detail locally.

Results: Using the base-case assumptions, a strategy of CT colonography for colorectal cancer screening would cost $2.27 million extra per 100 000 patients screened; 3.78 perforation-related deaths would be avoided, but 4.11 extra deaths would occur from missed adenomas. Because screening with CT colonography would cost more and result in more deaths overall compared with colonoscopy, the latter remained the dominant strategy. Our results were sensitive to CT colonography's test performance characteristics, the malignant risk of missed adenomas, the risk of perforation and related death, the procedural costs and differences in screening adherence.

Interpretation: At present, CT colonography cannot be recommended as a primary means of population-based colorectal cancer screening in Canada.

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