Projected Colorectal Cancer Incidence and Mortality Based on Observed Adherence to Colonoscopy and Sequential Stool-Based Screening

Reinier G S Meester; Iris Lansdorp-Vogelaar; Sidney J Winawer; Timothy R Church; John I Allen; Andrew D Feld; Glenn Mills; Paul A Jordan; Douglas A Corley; Chyke A Doubeni; Anne I Hahn; Stephanie M Lobaugh; Martin Fleisher; Michael J O'Brien; Ann G Zauber

doi:10.14309/ajg.0000000000002693

Projected Colorectal Cancer Incidence and Mortality Based on Observed Adherence to Colonoscopy and Sequential Stool-Based Screening

Am J Gastroenterol. 2024 Mar 20. doi: 10.14309/ajg.0000000000002693. Online ahead of print.

Authors

Affiliations

¹ Public Health Department, Erasmus MC, Rotterdam, the Netherlands.
² Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
³ Division of Environmental Health Sciences, University of Minnesota School of Public Health, and Masonic Cancer Center, Minneapolis, Minnesota, USA.
⁴ Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA.
⁵ Gastroenterology Clinic, Kaiser Permanente Washington (KPWA), Seattle, Washington, USA.
⁶ Feist-Weiller Cancer Center, Health Department, Louisiana State University, Shreveport, Louisiana, USA.
⁷ Division of Research, Kaiser Permanente, San Francisco, California, USA.
⁸ Family Medicine, Mayo Clinic, Rochester, Minnesota, USA.
⁹ Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
¹⁰ Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
¹¹ Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, Massachusetts.

PMID: 38318949
DOI: 10.14309/ajg.0000000000002693

Abstract

Introduction: Modeling supporting recommendations for colonoscopy and stool-based colorectal cancer (CRC) screening tests assumes 100% sequential participant adherence. The impact of observed adherence on the long-term effectiveness of screening is unknown. We evaluated the effectiveness of a program of screening colonoscopy every 10 years vs annual high-sensitivity guaiac-based fecal occult blood testing (HSgFOBT) using observed sequential adherence data.

Methods: The MIcrosimulation SCreening ANalysis (MISCAN) model used observed sequential screening adherence, HSgFOBT positivity, and diagnostic colonoscopy adherence in HSgFOBT-positive individuals from the National Colonoscopy Study (single-screening colonoscopy vs ≥4 HSgFOBT sequential rounds). We compared CRC incidence and mortality over 15 years with no screening or 10 yearly screening colonoscopy vs annual HSgFOBT with 100% and differential observed adherence from the trial.

Results: Without screening, simulated incidence and mortality over 15 years were 20.9 (95% probability interval 15.8-26.9) and 6.9 (5.0-9.2) per 1,000 participants, respectively. In the case of 100% adherence, only screening colonoscopy was predicted to result in lower incidence; however, both tests lowered simulated mortality to a similar level (2.1 [1.6-2.9] for screening colonoscopy and 2.5 [1.8-3.4] for HSgFOBT). Observed adherence for screening colonoscopy (83.6%) was higher than observed sequential HSgFOBT adherence (73.1% first round; 49.1% by round 4), resulting in lower simulated incidence and mortality for screening colonoscopy (14.4 [10.8-18.5] and 2.9 [2.1-3.9], respectively) than HSgFOBT (20.8 [15.8-28.1] and 3.9 [2.9-5.4], respectively), despite a 91% adherence to diagnostic colonoscopy with FOBT positivity. The relative risk of CRC mortality for screening colonoscopy vs HSgFOBT was 0.75 (95% probability interval 0.68-0.80). Findings were similar in sensitivity analyses with alternative assumptions for repeat colonoscopy, test performance, risk, age, and projection horizon.

Discussion: Where sequential adherence to stool-based screening is suboptimal and colonoscopy is accessible and acceptable-as observed in the national colonoscopy study, microsimulation, comparative effectiveness, screening recommendations.

Abstract

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