Clinical and budget impact of various CRC screenings

From the Roth Group, Division of Public Health Sciences

Colorectal cancer (CRC) is the second most common cause of cancer mortality. CRC is largely asymptomatic during the early stages and curative treatment options for patients with advanced-stage disease are limited. However, early detection of CRC can be achieved through screening, which increases the likelihood of survival if cancer is detected. Without CRC screening, patients could have 3 times the risk of mortality. A population-based survey in 2012, with 200,000 participants, estimated that 65% of Americans aged 50 to 75 years received the recommended screening guidelines for CRC. Because of the previous statistics, the National Colorectal Rountable’s mission was to increase CRC screening rates to 80% by raising awareness of CRC and promoting screening techniques. The different US Food and Drug Administration approved screening modalities are now listed by the US Preventive Services Task Force (USPSTF). They include a blood-based screen to detect circulating methylated Septin 9 (SETPT9) DNA (Epi proColon) and a multianalyte stool test combining fecal immunochemical testing (FIT) and fecal DNA (Cologuard; FIT/stool DNA). Both screening methods are less invasive than a traditional colonoscopy and will hopefully increase screening participation by 35% for eligible Americans. A recent study reported that patients who declined the standard colonoscopy and a stool screening test twice, had a 99.5% participation rate for the blood-based screening test.

The Roth group (Public Health Sciences Division) conducted a study to determine the impact of these alternative screening approaches on patient participation/compliance. This study, presented in the journal of American Health Drug Benefits, focused on 50-to-64-year old screening-eligible population because of this population’s screening gap and applicability to financial insurers. The objective of the study was to quantify/estimate the clinical and fiscal impacts on health plans, which includes the clinical and fiscal implications of the use of blood-based screening with SEPT9 DNA, FIT, and FIT/stool DNA of expanding CRC screening participation, for CRC patients who are resistant to or unable to be tested by other recommended screening methods. The researchers also predicted the CRC screening participation from today’s level of 65% up to 80%.

The authors developed a simulation model to calculate the 3-year aggregate health outcomes and costs for CRC screening among the screening-eligible population (50 – 75 years old) with no evidence of prior screenings. For the model inputs, they combined validated studies for blood and fecal based CRC screening tests, the US census, and other sources in literature. A hypothetical population of 1 million members of a commercial health plan was modeled. Approximately 232,000 members of the commercial health plan were eligible for screening; 150,800 members were not eligible/up to date for screening. The unscreened population consisted of 81,227 members, which was 35%. In order to reach the target goal of 80% of CRC screening, 34,862 members needed to be screened. In addition, Roth et al. estimated the cost of achieving 80% participation over a 3-year period ($185,662). As a result of the simulation for SEPT9, the estimated per-member, per month (PMPM) cost impact (vs. no screening) for the 1- and 3-year projections were $.40 and $.67, respectively. For FIT testing, the 1- and 3-year projections for the PMPM cost impact (vs. no screening) were $0.19 and $0.33, respectively. For the FIT/stool DNA, the 1- and 3-year projections for PMPM cost impact was $0.79 and $0.69, respectively. 


Graphical representation  Direct medical expenditure increases associated with reaching screening objective of 80% of eligible via blood-based and fecal-based screening methods
Direct medical expenditure increases associated with reaching screening objective of 80% of eligible via blood-based and fecal-based screening methods Image from Dr. Joshua Roth



The above figure shows that the screening cost was similar to the CRC treatment cost; however, it was higher than the diagnostic follow-up costs. Dr. Joshua Roth, who led the study, elaborates on the findings: “the corresponding expected economic impacts to the hypothetical 1 million member commercial health plan were increased spending of $25.6m for SEPT9 vs. no screening, $12.0m for FIT, and $24.8m for FIT/DNA testing if not considering the cost of CRC treatment. With CRC treatment costs included, the expected economic impacts were increased spending of $45.6m for SEPT9 vs. no screening, $31.0m for FIT, and $40.7m for FIT/DNA testing.”

Dr. Roth concludes that in order to improve screening, patient preferences should be considered in health plan decisions about promoting the use of blood and fecal based screening techniques. Also, he stated, “Future studies are needed to elicit patient preferences for these tests so that the test(s) most likely to increase CRC screening rates can be identified and promoted within commercial health plans in the United States.” Due to recent studies and the simulation model, more screening-eligible patients are more likely to have blood-based testing than fecal-based testing. These findings may help healthcare stakeholders evaluate the clinical and fiscal tradeoffs of alternative approaches that may help to increase CRC screening participations in the United States.

Funding for this study was provided by Epigenomics.

Fred Hutch/UW Cancer Consortium member: Joshua Roth and Scott Ramsey.

Roth JA, DeVos T, Ramsey SD. Clinical and Budget Impact of Increasing Colorectal Cancer Screening by Blood-and Stool-Based Testing. American Health & Drug Benefits. 2019 Sep 1;12(5).