Optimizing Benefits Versus Burden in Colorectal Cancer Screening

Author Dr. Mark Fendrick is the director of the Center for Value-Based Insurance Design at the University of Michigan and professor in internal medicine and health management and policy.

Although effective screening tools to prevent or detect cancer at earlier, more treatable stages have been available for decades, colorectal cancer (CRC) remains the second leading cause of cancer death in the United States.[i]  The challenge as to why many people remain unscreened or don’t complete the screening process isn’t just clinical; it’s logistical. The supply of clinicians who perform colonoscopy – the ‘gold standard’ CRC screening modality – is finite and unable to meet demand, partially due to COVID-19 pandemic disruptions and the U.S. Preventive Services Task Force (USPSTF) recommendation to begin screening at age 45 added approximately 20 million newly eligible adults.[ii]^,[iii]  Given that 6 million of the 15 million colonoscopies performed in the U.S. annually are available for screening[iv] a profound shortage exists.ⁱⁱⁱ Thus, to achieve the full clinical and economic benefits of screening, high-performing noninvasive modalities must be used more frequently.

A shift away from screening colonoscopy aligns with patient preferences, as many unscreened patients simply avoid colonoscopy — due to fear, inconvenience, or lack of awareness.[v]  A recent Current Medical Research and Opinion (CMRO) publication on predictive preference for non-invasive testing reported that while clinicians overwhelmingly preferred colonoscopy, patients strongly prefer noninvasive, stool-based options.[vi]

Why Efficiency Matters: Making the Most of Every Screening Opportunity

Evidence-based tools exist to assist in choosing among available noninvasive options.  USPSTF has used 'efficiency' to describe how well a screening modality balances benefit (life-years gained, cancers prevented) against burden (procedures, cost, patient effort). A recent Journal of the National Cancer Institute publication advanced this concept through the use of an ‘efficient frontier’, that quantified which tests deliver the most benefit for the least burden.[vii] The modeling study concluded that next-generation multitarget stool DNA (mt-sDNA) was the most efficient noninvasive screening test at guideline-recommended interval and age ranges.  

Moreover, when systems choose among noninvasive tests, components such as real-world adherence to the initial screening test and recommended follow-up colonoscopy must also be included.  As such, analyses that focus solely on cost of screening do not capture the full clinical and economic value and will always favor lower-cost, lower-performance tests. When both screening and treatment are considered, modeling studies show that a mt-sDNA screening yielded both superior clinical and financial outcomes (driven by cancers prevented and lower treatment costs) compared to lower cost FIT testing resulting in a more efficient screening program.[viii]

Follow-Up Matters: Turning Detection Into Prevention

An initial non-invasive screening test only delivers its full benefit when patients complete a follow-up colonoscopy after a positive result. Every completed follow-up colonoscopy represents an opportunity to detect and remove precancerous lesions, stopping cancer before it starts and allows cancers to be detected at a more treatable stage. In a study of 360,000+ patients published in CMRO, 77% of patients who completed multitarget stool DNA (mt-sDNA) testing followed through with colonoscopy, compared with 45% of those who used FIT or FOBT.[ix] In light of these differences, interventions are needed to ensure that everyone completes screening process

Putting into Practice: Closing the Gap with High-Performing Non-Invasive Tests

Health systems face growing pressure to expand CRC screening while managing limited endoscopy resources. By increasing the use of high-performing noninvasive tests for initial CRC screening, the fixed supply of colonoscopy procedures can be directed toward those higher-risk individuals who are symptomatic, require surveillance, or have positive noninvasive results. Choosing an initial non-invasive CRC screening test that performs well on the efficiency frontier (e.g. mt-sDNA) offers an opportunity for providers to optimize the health and economic gains from screening while mitigating the burden associated with the process. Such an approach ensures that the use of fixed supply of colonoscopies performed delivers maximal clinical and financial value and closely aligns with forthcoming NCQA quality measures that will evaluate systems on timely follow-up colonoscopy after positive noninvasive results.[x] By optimizing capacity, systems can extend reach and improve outcomes, without expanding endoscopy infrastructure.

Dr. Fendrick has been a consultant for Exact Sciences but was not compensated for this article.