Effectiveness and economic impact of screening for colorectal cancer by mass fecal occult blood testing

OBJECTIVES: Fecal occult blood testing has been shown to reduce mortality f rom colorectal cancer in large randomized, controlled trials conducted in t he United States, Denmark, and the United Kingdom, and mathematical simulat ion modeling found it to be cost-effective relative to other health care se rvices. Before making a concerted effort to implement mass fecal occult blo od testing based on this evidence alone, however, we considered it prudent to critically re-evaluate the effectiveness and economic impact of screenin g in the US population as a whole. METHODS: To assess the effectiveness of screening, we projected published o utcomes from each of the three large randomized controlled trials of fecal occult blood testing to the US population, as if each clinical trial had be en done in the population as a whole. We then determined the resource costs of detection and treatment that would be associated with the. outcomes pre dicted from each trial. RESULTS: More than 1 million colorectal cancers could be expected to arise over 10 yr in the cohort of US residents eligible to enter a screening prog ram in 1997, and trial outcomes indicate that greater than or equal to 60% of these cancers would be fatal. If:the 60-67% compliance rate of the popul ation-based randomized controlled trials were achieved, a fecal occult bloo d testing program would detect 30% of known colorectal cancers and save 100 ,000 lives over 10 yr. Screening would incur total costs of $3-4 billion ov er 10 yr, or $2,500 per life-year saved. CONCLUSIONS: Mass fecal occult blood testing is cost-effective, and, althou gh not inexpensive, many would consider the total cost acceptable. Even wit h a concerted effort to achieve compliance, however, the effectiveness of f ecal occult blood testing would be limited to saving the lives of less than or equal to 15% of those who otherwise would die from their cancer in the first 10 yr after beginning mass screening. The limitations of fecal occult blood testing suggest the need to further evaluate the role of endoscopy i n screening, and to develop more effective, noninvasive screening tools. (C ) 2000 by Am. Cell. of Gastroenterology.