CRC screening at age 45 What does the modeling suggest?

Transcription

1 CRC screening at age 45 What does the modeling suggest? Elisabeth Peterse Erasmus University Medical Center, Rotterdam, The Netherlands

2 Possible conflicts of interest No disclosures. Elisabeth Peterse

3 Background In 2016, the CISNET models performed analyses for the United States Preventive Services Task Force Two out of three CISNET models recommended screening from age 45 to 75 years with a 15 year colonoscopy interval. MISCAN-Colon (microsimulation model from Erasmus) recommended screening from age 50 to 75 years with a 10 year colonoscopy interval. 2018: Update screening guideline American Cancer Society Re-evaluation of the optimal screening strategies using MISCAN-Colon Elisabeth Peterse

4 Increase in young-onset CRC While overall incidence is declining, incidence <50 is increasing Rectal Cancers Elisabeth Peterse Siegel et al. JNCI 2017

5 Aim The CISNET models are calibrated to data This period is selected because there was no screening in this period They do not take the recent increase in young-onset CRC into account Research question: Are the optimal age to start screening, age to end screening and screening interval affected by the increase in CRC incidence rate observed in young adults? Elisabeth Peterse

6 Methods Elisabeth Peterse

7 Incorperation higher incidence in MISCAN-Colon Cohort Rate Ratio Set as a reference as this cohort is 40 in 1975 (model is calibrated on ) Used as model input for increased incidence as these are the 40-year-olds in 2015 As it is a cohort effect, we assumed that the current 40 year olds will carry forward an increased CRC risk when they age Provided by Rebecca L. Siegel, American Cancer Society

8 Strategies analyzed We simulated a population of 40-year-olds without previous CRC screening We assumed perfect adherence to screening, diagnostic follow-up and surveillance Screening Modality Age to Start Screening (years) Age to End Screening (years) Screening Interval (years) No. Of (Unique) Strategies No screening 1 (1) Colonoscopy 40,45,50 75,80,85 5,10,15 27 (20) Stool-based tests - Fecal immunochemical test 40,45,50 75,80,85 1,2,3 27 (27) - High-sensitivity guaiac-based fecal occult blood test 40,45,50 75,80,85 1,2,3 27 (27) - Multitarget stool DNA test 40,45,50 75,80,85 1,3,5 27 (27) Flexible sigmoidoscopy 40,45,50 75,80,85 5,10 18 (15) Computed tomographic colonography 40,45,50 75,80,85 5,10 18 (15) Total 145 (132) Elisabeth Peterse

9 Main outcomes Life-years gained (benefit) Number of colonoscopies (burden) Efficiency Ratio= Incremental colonoscopies w.r.t. previous efficient strategy Incremental life-years gained w.r.t. previous efficient strategy Applied efficiency ratio thresholds of 40 Based on the accepted 39 in USPSTF analysis Elisabeth Peterse

10 Results Elisabeth Peterse

11 Efficient Frontier Colonoscopy Screening strategies Elleke Peterse

12 Step 1: In or near the efficient frontier Elleke Peterse

13 Step 2: Effective as current recommendation

14 Step 3: Efficiency ratio < 40 ΔLYG ΔCOL Efficiency Ratio = ΔCOL ΔLYG = 32

15 Step 3: Efficiency ratio < 40 ER=32 ER=48

16 Step 3: Efficiency ratio < 40 ER=32 ER=48

17 Step 4: Select the most effective strategy ER=32 ER=48 Elleke Peterse

18 Model recommendations Modality Age to start screening (years) Age to stop screening (years) Screening interval (years) Stool tests Results per year-olds SIGs CTCs COLs Life-years gained CRC Deaths Averted Colonoscopy Stool test: FIT Flexible Sigmoidoscopy CT colonography Elisabeth Peterse

19 Conclusion Because of the increase in young-onset colorectal cancer, screening initiation at age 45 has a favorable balance between screening benefits and burden. Elisabeth Peterse

20 Acknowledgements Department of Public Health, Erasmus MC, Rotterdam, The Netherlands Reinier G.S. Meester Iris Lansdorp-Vogelaar Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Ann G. Zauber Jennifer C. Chen American Cancer Society, Atlanta, GA, USA Rebecca L. Siegel Robert A. Smith University of Colorado Cancer Center, Aurora, CO, USA Andrea Dwyer Dennis J. Ahnen Elisabeth Peterse

21 Elisabeth Peterse

22 Population Simulation Model Input MISCAN program Output Results Demography assumptions Natural history assumptions (incl. risk level) Screening assumptions Demography part Natural history part Screening part Cancer incidence and mortality without screening Cancer incidence and mortality with screening Effects of screening Elleke Peterse

23 Important assumptions We modelled the 1975 birth cohort, so we increased incidence by Incidence rate ratios from 1.2, 1.3, 2.3 and 2.4 explored in a sensitivity analyses As it is a cohort effect, we assumed that the current 40 year olds will carry forward an increased CRC risk when they age In a sensitivity analyses, we only increased incidence below age 50 We assumed that the increase in CRC incidence was caused by an increase in adenoma onset We explored faster adenoma progression in a sensitivity analyses Elleke Peterse

24 A cohort effect Increase is higher in whites than in blacks Increase is mainly present in rectal tumors and, to a lesser extend, in distal colon tumors Siegel et al. JNCI 2017, Siegel et al. CA 2017

25 Modality, and Age to Start, Age to End, Interval (years) Stool tests SIGs CTCs COLs LYG CRC Deaths Averted ER = ΔCOL/ ΔLYG ER < Benchmark LYG >= 90% of Benchmark Colonoscopy COL Yes Stool tests FIT Yes No FIT Yes No HSgFOBT Dom. - No FIT-DNA Dom. - No HSgFOBT Dom. - No FIT-DNA Dom - No FIT Yes Yes Yes HSgFOBT Dom. - Yes FIT-DNA No Yes Flexible sigmoidoscopy SIG Yes No SIG Yes Yes Yes CT colonography CTC Yes No CTC Yes Yes Yes Model Recom.

26 Efficient and near-efficient colonoscopy strategies Modality, and Age to Start, Age to End, Interval (years) Stool tests SIGs CTCs COLs LYG CRC Deaths Averted ER = ΔCOL/ ΔLYG COL COL * COL COL * COL COL * COL COL COL COL * COL * COL COL COL Nearefficient

27 Sensitivity analyses

28 Annual Percent Change (APC) in CRC mortality rates among adults aged 20 to 54 years Siegel et al. JAMA 2017

29 Efficient Frontier Stool-based strategies

30 Algorithm to find recommendable strategies