The impact of adherence on colorectal cancer screening cost-effectiveness: A modeling study

Jiaxin Xie, Xuesi Dong, Zilin Luo, Chenran Wang, Yadi Zheng, Xiaolu Chen, Zeming Guo, Xiaoyue Shi, Fei Wang, Wei Cao, Yongjie Xu, Le Wang, Weimiao Wu, Dong Hang, Lingbin Du and Ni Li

PLOS Medicine, 2025, vol. 22, issue 11, 1-16

Abstract: Background: Adherence to colorectal cancer (CRC) screening remains suboptimal in many countries, reducing its cost-effectiveness. This study aimed to evaluate how multistage uptake rates influence the health benefit and cost-effectiveness of various CRC screening strategies in the Chinese population, incorporating both traditional and emerging screening methods. Methods and findings: We developed a multistate Markov model (CRC-SIM) to evaluate the impact of multistep uptake on CRC screening. A hypothetical cohort of 100,000 individuals aged 40 was simulated and followed until 79 or death. Two-step screening strategies were modeled: initial screening followed by colonoscopy after a positive result. Traditional initial screening methods include: questionnaire-based risk assessment, fecal immunochemical test (FIT), and questionnaire combined with FIT; Non-invasive biomarker-based initial strategies include a hypothetical test meeting the minimum standards of China National Medical Products Administration (NMPAmin), multitarget stool DNA (mt-sDNA) test, and blood-based strategies. All strategies were modeled as one-time screenings, with outcomes projected for CRC cases, deaths, quality-adjusted life years (QALYs), and lifetime costs. Incremental cost-effectiveness ratios (ICERs) were calculated, and a cost-effectiveness heatmap was conducted to assess the impact of multistep uptake (modeled in 10% steps) on economic outcomes. All strategies reduced CRC cases, deaths and increased QALYs compared to no screening, with biomarker-based strategies outperforming the traditional methods at the same uptake level (e.g., questionnaire combined with FIT prevented 224 (95% confidence interval (CI) [157, 292]) CRC cases and 151 (95% CI [109, 195]) deaths, whereas NMPAmin prevented 312 (95% CI [257, 360]) cases and 210 (95% CI [175, 241]) deaths at 100% uptake). The cost-effectiveness heatmap indicated that each 10% increase in initial and follow-up colonoscopy uptake improved ICERs in a non-linear pattern. The questionnaire combined with FIT was the most cost-effective strategy (ICER = $2,413 per QALY gained). Non-invasive biomarker-based tests were not cost-effective compared with the combined questionnaire and FIT strategy under current assumptions of test costs and identical uptake rate. Threshold analysis showed that non-invasive biomarker-based screening would become cost-effective if test costs fell below $131.7 or colonoscopy uptake increased to at least 70% for NMPAmin and 50% for blood-based tests and mt-sDNA. Limitations include the assumption of a one-time screening scenario; future iterations of the model and merging evidence in repeated screening will address these limitations. Conclusion: Improving screening participation could enhance health benefits and cost-efficiency in CRC screening. Questionnaire-based risk assessment combined with FIT was a cost-effective strategy in China, whereas non-invasive biomarker-based methods require cost reduction and higher uptake to justify adoption. These findings provide evidence for policymakers to optimize CRC screening programs. Why was this study done?: What did the researchers do and find?: What do these findings mean?: Jiaxin Xie, Xuesi Dong, Zilin Luo, and team use a multistate Markov model to quantify the long-term health and economic benefits of adhering to colorectal cancer screening, incorporating both traditional and biomarker-based initial screening methods.

Date: 2025
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Persistent link: https://EconPapers.repec.org/RePEc:plo:pmed00:1004807

DOI: 10.1371/journal.pmed.1004807

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