Colorectal Cancer Screening - Economic Considerations

1. Colorectal Cancer Screening -Economic Considerations Terri Green University of Canterbury Presentation for “Future of Cancer Screening in New Zealand”. Auckland, 7 August 2015

2. Economic considerations • Is it value for money? (Yes, potentially) • What are the benefits? • What are the costs? • Can we achieve the benefits? • Can we afford it? • Are there alternatives?

4. Fig 3. Biennial FOBTi screening, 50-74 years: Referral and Surveillance colonoscopy 2011-2031(Participation 60%, Positivity 6.4%, 4.8%)Green, Richardson and Parry (NZMJ, 2012)

5. Can we do it? • 18000 colonoscopies rising to 28000 • Assumes • Participation 60% Compared to 55% for pilot • Positivity 6.4% for initial screen • 4.8% for later screens Compared to 7.5% for pilot

6. What is the cost of Programme?-estimated at $39 M per year* (Sapere, 2015)(Steady state cost; initial years more costly) Key Determinants of cost: • Participation rate in screening (pilot, 55%) • Positivity rate (pilot, 7.5%) • How programme is delivered: • Use of private sector for colonoscopies • Regional variations (*Range $26M-$50M, Sapere report MOH 2015)

7. Can we afford “it”? • Depends on other demands on public money …… (Annual CRC treatment costs approx $83M*.) • If it can be delivered it is worthy of consideration • Are there alternatives to address Bowel cancer? E.G. screening by once only Flexible Sigmoidoscopy. (*Sheerin, Green, Sarfati, Cox, NZMJ 2015)

8. Approx Comparison: Annual volumesFOBTi and Flexible Sigmoidoscopy(60% participation) FOBTi (50-74, every 2 years) Flex sig (one-off, age 55) 60,000 target 36,000 screens 1800* colonoscopies (* 5%, Atkins, Lancet, 2010) • 618,000 target • 371,000 screens • 18,000 colonoscopies

9. Balancing costs and benefits:- FOBTi , compared to Flex sig • Greater Reduction in CRC incidence√ • Greater Reduction in mortality √ • Higher cost • Lower cost per QALY √ • More adverse events • Higher colonoscopy load