Cost-effectiveness analysis of screening strategy for second primary colorectal cancer screening in Korean male cancer survivors
Sang Min Park MD,MPH, PhD,1,2,*
1
Department of Population and International Health, Harvard School of Public Health, Boston, MA, National Cancer Center, Goyang, Gyeonggi, Korea Current address: Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
USA
2
*
Potential Financial Conflicts of Interest: None disclosed. Word Count for Text: 1,617 Keywords: Cost-effectiveness, Second primary colorectal cancer, Screening, Cancer survivor
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INTRODUCTION
With the advances in treatment and early diagnosis, the number of cancer survivors are continually increasing, and this has raised the issue of second primary cancers (SPC) in cancer survivors.1-4 One study in Korea showed that the age-standardized incidence rate was 2.3 times higher for an SPC than for a first cancer, and the age-standardized incidence rate was about 4 times higher for second than for first primary colorectal cancers (CRC).5 Colorectal cancer screening are well established to reduces the cancer-related mortality through detection of malignancy at an earlier stage as well as by identification and removal of pre-cancerous adenomatous polyp.6 Therefore, several panel have recommended colorectal cancer screening for the general population with the cost-effectiveness (CE) of CRC screening for the general population.6-12 Due to the difference of life expectancy and the risk of CRC between cancer survivors and general population, colorectal cancer screening guidelines could be different in cancer survivors. To suggest a feasible economic strategy of CRC screening for cancer survivors in Korea, we compared the cost-effectiveness results of CRC screening between in cancer survivors and in the average-risk general population.
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METHODS The natural history of a simulated male cancer survivors' cohort was modeled with and without second primary colorectal cancer screening until age of 75 years. We assumed that all male cancer survivors enter at age 50, which most guidelines for the general population recommended for starting colorectal cancer screening.10-12 We developed a Markov model using TreeagePro 2007 software, to compare 8 different screening strategies as follows: 1) no screening, 2) fecal occult blood test (FOBT) annually (FOBT1), 3) FOBT every two years (FOBT2), 4) sigmoidoscopy every 5 years (SIG5), 5) double contrast barium enema every 5 years (DCBE5), 6) colonoscopy every 10 years (COL10), 7) colonoscopy every 5 years (COL5), and 8) colonoscopy every 3 years (COL3). Subjects were placed into health states defined by the presence or absence of a colorectal polyp or second primary colorectal cancer (early or advanced) after 1 year of the index cancer diagnosis. Cases of positive screening test results were worked up with a colonoscopy, and individuals diagnosed with polyp underwent polypectomy. The probability of perforation was assigned to colonoscopy, sigmoidoscopy, double contrast barium enema and polypectomy.8,13,14 Mortality caused by the risk of perforation was assumed to be 0.02%.9,14 Colonoscopy was repeated every 3 years for surveillance after polypectomy.15 We assumed that 80% of male cancer survivors underwent the initial screening test, independent of whether they were compliant with past tests. The compliance of follow-up or surveillance colonoscopy was assumed to be 100%. We also assumed that 90% of

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