Colorectal cancer screening at age 45 years in Israel: Cost-effectiveness and global implications

Elizabeth E Half; Zohar Levi; Ajitha Mannalithara; Moshe Leshno; Irit Ben-Aharon; Naim Abu-Freha; Barbara Silverman; Uri Ladabaum

doi:10.1002/cncr.35097

Colorectal cancer screening at age 45 years in Israel: Cost-effectiveness and global implications

Cancer. 2024 Mar 15;130(6):901-912. doi: 10.1002/cncr.35097. Epub 2024 Jan 5.

Authors

Elizabeth E Half^{1

2}, Zohar Levi^{3

4}, Ajitha Mannalithara⁵, Moshe Leshno^{4

6}, Irit Ben-Aharon^{2

7}, Naim Abu-Freha^{8

9}, Barbara Silverman¹⁰, Uri Ladabaum⁵

Affiliations

¹ Gastroenterology Institute, Rambam Health Care Campus, Haifa, Israel.
² The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
³ Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.
⁴ Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
⁵ Division of Gastroenterology and Hepatology, Department of Medicine, Stanford School of Medicine, Stanford University, Stanford, California, USA.
⁶ Coller School of Management, Tel Aviv University, Tel Aviv, Israel.
⁷ Division of Oncology, Rambam Health Care Campus, Haifa, Israel.
⁸ Department of Gastroenterology and Hepatology, Soroka University Medical Center, Beer Sheva, Israel.
⁹ Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
¹⁰ Israel National Cancer Registry, Ministry of Health, Ramat Gan, Israel.

PMID: 38180788
DOI: 10.1002/cncr.35097

Abstract

Background: Colorectal cancer (CRC) incidence at ages <50 years is increasing worldwide. Screening initiation was lowered to 45 years in the United States. The cost-effectiveness of initiating CRC screening at 45 years in Israel was assessed with the aim of informing national policy and addressing internationally relevant questions.

Methods: A validated CRC screening model was calibrated to Israeli data and examined annual fecal immunochemical testing (FIT) or colonoscopy every 10 years from 45 to 74 years (FIT45-74 or Colo45-74) versus from 50 to 74 years (FIT50-74 or Colo50-74). The addition of a fourth colonoscopy at 75 years was explored, subanalyses were performed by sex/ethnicity, and resource demands were estimated.

Results: FIT50-74 and Colo50-74 reduced CRC incidence by 57% and 70% and mortality by 70% and 77%, respectively, versus no screening, with greater absolute impact in Jews/Other versus Arabs but comparable relative impact. FIT45-74 further reduced CRC incidence and mortality by an absolute 3% and 2%, respectively. With Colo45-74 versus Colo50-74, CRC cases and deaths increased slightly as three colonoscopies per lifetime shifted to 5 years earlier but mean quality-adjusted life-years gained (QALYGs) per person increased. FIT45-74 and Colo45-74 cost 23,800-53,900 new Israeli shekels (NIS)/QALYG and 110,600-162,700 NIS/QALYG, with the lowest and highest values among Jewish/Other men and Arab women, respectively. A fourth lifetime colonoscopy cost 48,700 NIS/QALYG. Lowering FIT initiation to 45 years with modest participation required 19,300 additional colonoscopies in the first 3 years.

Conclusions: Beginning CRC screening at 45 years in Israel is projected to yield modest clinical benefits at acceptable costs per QALYG. Despite different estimates by sex/ethnicity, a uniform national policy is favored. These findings can inform Israeli guidelines and serve as a case study internationally.

Keywords: colon cancer; colorectal cancer; cost-effectiveness; prevention; screening age initiation.

MeSH terms

Colonoscopy
Colorectal Neoplasms* / diagnosis
Colorectal Neoplasms* / epidemiology
Cost-Benefit Analysis
Early Detection of Cancer*
Female
Humans
Israel / epidemiology
Male
Mass Screening
Middle Aged
Occult Blood
United States