COLORECTAL CANCER (Screening)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 8/08/11

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years.1

Evidence Rating: A (Recommended/ Strong Evidence)
The USPSTF concludes that, for fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy to screen for colorectal cancer, there is high certainty that the net benefit is substantial for adults age 50 to 75 years.1

NOTE:
The USPSTF recommends against routine screening for colorectal cancer in certain populations. For more information, see C and D recommendations.

The USPSTF has insufficient evidence for the use of other screening modalities for colorectal cancer. For more information, see I recommendations.




The Value of Prevention

Economic Burden of Condition/Disease
The annual expenditure for colorectal cancer was conservatively estimated to equal $8.4 billion in 2004.6 A more recent study projected that the costs of colorectal cancer care to the Medicare program would increase to $14.02 billion in 2020 from $7.49 billion in 2000 after accounting for decreased incidence, improved survival, and increased costs of care (based on 2002 dollars).7

Because colorectal cancer is a disease of middle and old age, the costs related to colorectal cancer treatment are likely to increase as the population ages. Based on 2008 trend predictions, the projected costs in 2020 in the initial, continuing, and last year of life in treating colorectal cancer are $5.19 billion, $3.57 billion, and $5.27 billion respectively. In individuals 65 and older, this represents an 89% increase in the costs of colorectal cancer care.8

Workplace Burden of Condition/Disease
Besides the health, disability, and life insurance costs for employees affected by colorectal cancer, lost productivity associated with morbidity and premature mortality contributes to significant additional costs. During 1998, colorectal patients were hospitalized for 2.3 million days — a work loss equivalent of $70.9 million in lost wages among the working-age population. This figure would increase to $106.1 million if time away from work due to care in all settings was considered.9

Economic Benefit of Preventive Intervention
Screening can prevent colorectal cancer by allowing clinicians to identify and remove precancerous polyps before they develop into cancer. Screening can also identify cancer early in the course of the disease when treatment is more effective and the chance of recovery is high. The cost of screening is typically less than the cost of treating cancer and, when screening identifies a colorectal tumor in its early stages, the cost of treatment is often much less expensive. In average-risk adults, economic models found that compared to colorectal cancer diagnosed at the local stage, the lifetime treatment cost is $7,000 more for regional stage and $16,000 for distant stage colorectal cancer.10

Estimated Cost of Preventive Intervention
The average cost of colorectal cancer screening varies by location and provider. The five recommended methods of screening for colorectal cancer have very different initial costs, with FOBT and colonoscopy being the least and most expensive methods respectively. However, because they are typically used at different time intervals and because colonoscopy is required to confirm results of the other methods, the 10-year overall cost for screening sequences that include diagnostic colonoscopy are similar. Table 1 lists the median price of colorectal cancer screening, by type. Cost estimates are based on 2007 data from privately-insured beneficiaries.11

Table 1: Median Private-Sector Cost of Colorectal Cancer Screening Methods (in year 2007 dollars)12
Screening Technique Median Price per Procedure Recommended Number of Over a
10-Year Period		 Median Price Over a 10-year Interval
Colonoscopy $432
(range $190 to $1,213)*		 1 $432
(range $190 to $1,213)*
Fecal occult blood test (FOBT)+; may require follow-up colonoscopy $5
(range $3 to
$28)*		 10 $45
(range $30 to
$280)*
Combination of flexible sigmoidoscopy and FOBT $140
(range $55 to
$605)*		 2 (sigmoidoscopy)
3 (FOBT)		 $284 (range $112 to $1237)*
* Approximately 95% of paid claims fell within the stated range.
+ The median price of FOBT is based on weighted frequencies of the two types of FOBTs and their median prices

Estimated Cost of Treatment
Economic models of screening in average-risk adults found that lifetime treatment cost is $24,000 for colorectal cancer diagnosed at the local stage, $31,000 for regional stage, and $40,000 for distant stage (using data from 2003).10

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
A systematic review of cost-effectiveness analyses for different colorectal cancer screening methods found that most common screening strategies for adults aged 50 years or more would result in an average cost-effectiveness ratio ranging from $10,000 to $30,000 per life-year saved (year 2000 dollars) compared to no screening.13 In comparison to other preventive interventions and to commonly accepted cost-effectiveness benchmarks, screening for colorectal cancer is cost-effective.


Condition / Disease Specific Information

Epidemiology of Condition/Disease
Colorectal cancer is the third most common cancer and the second leading cause of cancer death in the United States.2 It is also a major cause of premature mortality. Patients who die of colorectal cancer lose 13 years of life, on average.3

The American Cancer Society (ACS) estimated that there would be 106,100 colon and 40,870 rectal cancer cases in the United States in 2009.2 Although mortality rates have continued to decline over the past 20 years, an estimated 49,920 deaths from colorectal cancer were predicted to occur in 2009, comprising about 9% of all cancer deaths.2

Early stage colorectal cancer is rarely symptomatic, therefore screening for early detection is indicated. Advanced stages of colorectal cancer may exhibit signs or symptoms such as rectal bleeding or blood in the stool, changes in bowel habits and lower abdominal cramping.2

Condition/Disease Risk Factors
Risk factors for colorectal cancer include the following:4,5
  • Increased age
  • Gender (being male)
  • Race (being African American)
  • A family history of colorectal cancer (including certain genetic conditions)
  • Personal history of inflammatory bowel disease
  • Diabetes
  • Overweight or obese
  • Physical inactivity
  • Tobacco use
  • Moderate to heavy alcohol consumption
  • Certain medications and dietary supplements
  • Consuming inadequate amounts of fruits and vegetables (possibly)



Preventive Intervention Information

Preventive Intervention: Purpose of Screening
The purpose of screening for colorectal cancer is to find precancerous polyps so that they can be removed before they turn cancerous, thus preventing the development of a tumor. Screening can also identify cancer early in the course of the disease when treatment is more effective and the chance of recovery is high.

Unfortunately, screening rates for colorectal cancer are low; fewer than half (48%) of privately insured adults aged 50-64 are screened at the recommended intervals.4

Benefits and Risks of Intervention
The benefits of screening are substantial. Routine screening can reduce the number of people who die of colorectal cancer by preventing cancer or identifying it in its earliest stages when treatment is most effective. While estimates of mortality reduction due to screening vary by type of screening test, the range is approximately 15% to 80%.14

The risks associated with screening depend on the type of screening method used. All of the recommended tests can produce false-positive results, which may lead to unnecessary procedures with resultant harms. Flexible sigmoidoscopy and colonoscopy may cause perforation and bleeding. However, the benefits of colorectal cancer prevention and early detection outweigh the risks of each of the currently recommended screening methods.1

Initiation, Cessation, and Interval of Screening
Screening for colorectal cancer should be initiated at age 50 for both men and women. For individuals who are determined by their physicians to be at higher risk of the disease, screening may be initiated at an earlier age.1 Screening has been found to be effective for people up to age 75.1 However, randomized trials suggest that life expectancy of at least 5 years may be required to realize the benefits of screening, so the risks and costs of screening may outweigh the benefits for people with reduced life expectancy because of age or illness.15

The optimal interval between screenings depends on the screening method used and is illustrated in Table 2.

Table 2: Colorectal Cancer Screening Methods and Recommended Intervals1
Screening Method Recommended Interval
Colonoscopy 10 years
Combination of flexible sigmoidoscopy and FOBT 5 years for the flexible sigmoidoscopy and 3 years for the FOBT
Fecal occult blood tests (FOBT) 1 year

Intervention Process
Approved methods of screening for colorectal cancer include colonoscopy, flexible sigmoidoscopy and fecal occult blood testing (FOBT). High-sensitivity FOBT is the preferred method of fecal occult blood testing (i.e. Sensa, Fecal Immunochemical Testing); older methods of FOBT (i.e. hemoccult II guaiac cards) are not as sensitive.

When a flexible sigmoidoscopy is conducted, a FOBT should also be utilized to improve the sensitivity of the tests. The approved FOBT test uses specimens collected in the patient's home.16 All abnormal test results should be verified by colonoscopy.4

Treatment Information
Health benefits should include provisions for diagnostic and treatment services.



Strength of Evidence

Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: A (Recommended/Strong Evidence)
  • The USPSTF found strong evidence that several screening methods are effective in reducing mortality from colorectal cancer. The USPSTF concluded with high certainty that the net benefit is substantial for adults age 50 to 75 years.1


Summary Plan Description

Covered Screening
  • Colonoscopy
  • Fecal occult blood testing (FOBT)
  • Flexible sigmoidoscopy
Initiation, Cessation, and Interval
Colorectal cancer screening is a covered benefit for men and women aged 50 to 75 years. Screening may be initiated at an earlier age if the beneficiary has certain risk factors and a clinician determines that the individual requires early screening.

Colorectal cancer screening intervals are based on the method of screening used:

Screening Method Approved Interval for Coverage
Colonoscopy Every 10 years
Fecal occult blood tests (FOBT) Every year
Combination of flexible sigmoidoscopy and FOBT Every five years for the flexible sigmoidoscopy and every three years for the FOBT

NOTE: Barium enema is no longer a recommended screening test because it has substantially lower sensitivity than current test strategies.



CPT Codes

Colorectal Cancer (Screening)
45378 Colonoscopy
45330 Sigmoidoscopy, flexible
82270 Fecal occult blood for colorectal neoplasm screening, by peroxidase activity, consecutive collected specimens with single determination
82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, 1-3 simultaneous determinations



Other Information and Resources

Business Group Resource(s)

CDC Resource



Author(s)

Campbell KP, Coates RJ, Chattopadhyay S. Colorectal cancer evidence-statement: screening. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006.

This section was updated, revised and re-written by Sajal Chattopadhyay in January 2010.



References

1 U.S. Preventive Services Task Force. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2008;149:627-637.
2 American Cancer Society. Cancer Facts & Figures 2009. Atlanta, GA: American Cancer Society; 2009.
3 Emmons KM, McBride CM, Puleo E, et al. Prevalence and predictors of multiple behavioral risk factors for colon cancer. Preventive Medicine. 2005;40(5):527-534.
4 American Cancer Society. Colorectal Cancer: Facts and Figures 2008-2010. Atlanta: American Cancer Society, 2008.
5 International Agency for Research on Cancer. IARC handbooks of cancer prevention: Weight control and physical activity, vol. 6. Lyon (France): IARC Press; 2002.
6 Brown ML, Riley GF, Schussler N, Etzioni RD. Estimating health care costs related to cancer treatment from SEER-Medicare data. Medical Care. 2002 Aug;40(8 Suppl):IV-104-17.
77 Yabroff KR, Mariotto AB, Feuer E, Brown ML. Projections of the costs associated with colorectal cancer care in the United States, 2000-2020. Health Economics. 2008;17:947-959.
8 Yabroff, K et al. Projections of the costs associated with colorectal cancer care in the United States, 2000-2020. Health Economics .August 2008; 17(8): 947-959.
9 The American Gastroenterological Association. The burden of gastrointestinal diseases. Bethesda, MD: American Gastroenterological Association; 2001. Available at: http://www.gastro.org/user-assets/Documents/burden-report.pdf. Accessed January 5, 2009.
10 Pignone M, Russell L, Wagner J, eds. Economic models of colorectal cancer screening in average-risk adults. Washington (DC): The National Academies Press; 2005.
11 Thomson Reuters. 2004 MarketScan® Commercial Commercial Claims and Encounters Database. 2005.
12 Thomson Reuters. 2007 MarketScan® Commercial Claims and Encounters Database. 2009.
13 Pignone M, Saha S, Heorgem T, Mandelblatt J. Cost-effectiveness analyses of colorectal cancer screening: a systematic review. Ann Internal Med. 2002;137:96-104.
14 U.S. Preventive Services Task Force. Colorectal Cancer Screening. Summary, Evidence Report: Number 1. AHCPR Publication No. 97-0302. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/clinic/colorsum.htm.
15 Walter LC, Covinsky KE. Cancer Screening in Elderly Patients: A Framework for Individualized Decision Making. JAMA. June 6, 2001 2001;285(21):2750-2756.
16 Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, et al. Evaluating Test Strategies for Colorectal Cancer Screening:A Decision Analysis for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2008;149:659-669.