The impact of National Bowel Cancer Screening Program in Australia

Lowy Cancer Research Centre

Jie-Bin Lew1,2, James St John3, Dayna Cenin4 , Xiang-Ming Xu1, Veerle Coupe5, Marjolein Greuter5, Michael Caruana1,2, Emily He1,2, Karen Canfell1,2

1. University of NSW, Australia 2. Cancer Council NSW, Australia 3. Cancer Council Victoria, Australia, 4. Cancer Council Western Australia, Australia 5. VU University Medical Center, The Netherlands,

Email: jiebin.lew@nswcc.org.au

Background Bowel cancer (also known as colorectal cancer) is the second

most common cancer in males and females in Australia In 2011:

~15,200 new bowel cancer cases (ASR: 67.8 per 100,000 persons) ~5,000 bowel cancer deaths (ASR: 17.8 per 100,000 persons)

Data source: AIHW 2015. Australian Cancer Incidence and Mortality (ACIM) books 2015

0

100

200

300

400

500

600

Rate

per

100

,000

per

son

Age group (year)

Australian bowel cancer incidence rate in 2011

Male

Female

0

50

100

150

200

250

300

Rate

per

100

,000

per

son

Age group (year)

Australian bowel cancer mortality rate in 2011

Male

Female

Background : National Bowel Cancer Screening Program (NBCSP)

Phase YearAge cohort invited to NBCSP (years)

50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 741 2006-2007 √ √ 2 2008-2012 √ √ √

3

2013-2014 √ √ √ √ 2015 √ √ √ √ √ √2016 √ √ √ √ √ √ √ √2017 √ √ √ √ √ √ √ √ √ √2018 √ √ √ √ √ √ √ √ √ √ √2019 √ √ √ √ √ √ √ √ √ √ √ √ √

2020 and later √ √ √ √ √ √ √ √ √ √ √ √ √

NBCSP phases and target population

Data Source: AIHW 2014. National Bowel Cancer Screening Program: Monitoring Report 2012-2013

By 2020, full implementation of the

biennial screening program for 50-74years

Screening program began

Prior estimates of predicted costs and impact• Pignone et al 2011:1

Estimated annual gross cost of a biennial iFOBT screening program for 50-74 years as ~ $150 million (did not consider surveillance and cancer treatment costs).

Assuming screening program would reduce mortality from bowel cancer by 15-25%, undiscounted cost per LYG of screening was estimated to be $25,000-41,667.

• Cenin et al 2014:2 – Estimated that accelerated implementation of the screening program to 2020 (as now occurring) will

be associated with a cumulative deaths prevented of 70,000 (equivalent to 1,750 deaths prevented per year) between 2015-2055.

– Total 4.9 million colonoscopies (equivalent to 125,000 per year) over the period between 2015-2055.– Did not consider costs

• No prior work has involved a comprehensive evaluation of the health outcomes, health services utilisation and costs over time.

Data Source: 1. Pignone MP, Flitcroft KL, Howard K, Trevena LJ, Salkeld GP, St John DJ. Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening

program for bowel cancer in Australia. Med J Aust 2011;194:180-5.2. Cenin DR, St John DJ, Ledger MJ, Slevin T, Lansdorp-Vogelaar I. Optimising the expansion of the National Bowel Cancer Screening Program. Med J Aust 2014;201:456-61.

Study Aims

To evaluate the impact of the fully rolled out NBCSP on health outcomes, resource utilisation and costs*.

*Excluding program overheads and costs of targeted initiatives – considering costs related to direct health services use only.

Methods: Adenoma and Serrated Pathway to Colorectal Cancer (ASCCA) model

Source: Greuter MJ, Xu XM, Lew JB, et al. Modelling the Adenoma and Serrated pathway to Colorectal CAncer (ASCCA). Risk Analysis 2014;34:889-910.

• First CRC model to incorporate the serrated pathway

• Microsimulation (individual-based) model.

• Simulates 20 million virtual individuals per age-cohort through life from age 20-89 years.

• Calibrated to the Dutch Colonoscopy versus Colonography Screening (COCOS) trial data, including age- and sex-specific rates of:

• Adenoma prevalence by lesion size• Adenoma multiplicity• % of adenoma with HG dysplasia• % of adenoma with villous

characteristics• Prevalence of advance adenoma• Advance adenoma multiplicity• Prevalence of HPs by size• Prevalence of SSAs by size• HPs multiplicity• SSAs multiplicity• Overall SA multiplicity• % of CRC developed via each pathway

Data sources• Follow-up of positive FOBT and colonoscopic surveillance intervals was modelled

based on guidelines.1,2

• Cost assumptions:– Screening, diagnosis and treatment were obtained from MBS, DRG-AG and published literature.3,4

– Program overhead cost and general program administrative cost not included

• Test characteristics of FOBT were informed by literature review and finalised via calibration to the overall observed FOBT positive rate in Australia in 2012-13.

• Test accuracy of colonoscopy was obtained from published literature5,6

• Base case screening participation for 2006-2013 based on the observed participation rate.

• Base case screening participation for 2014 onwards based on current rates, interpolated rates for new age cohorts.

Reference: 1. Cancer Council Australia Colonoscopy Surveillance Working Party. Clinical Practice Guidelines for Surveillance Colonoscopy – in adenoma follow-up; following curative resection of

colorectal cancer; and for cancer surveillance in inflammatory bowel disease. Cancer Council Australia, Sydney (December 2011). 2. Barclay Karen, Cancer Council Australia Surveillance Colonoscopy Guidelines Working Party. Colonoscopic Surveillance Intervals – Adenomas. 20133. Pignone MP, Flitcroft KL, Howard K, Trevena LJ, Salkeld GP, St John DJ. Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening program for

bowel cancer in Australia. Med J Aust 2011;194:180-5.4. Ananda SS, Tran B, Kosmider S, Field K, Gibbs P. Calculating the rapidly escalating cost of treating colorectal cancer: time for an increased focus on prevention and screening. Poster

session presented at: Australia Gastrointestinal Trials Group 11th Annual Scientific Meeting. 26–28 August 2009; Brisbane, Australia5. van Rijn JC, Reitsma JB, Stoker J, Bossuyt PM, van Deventer SJ, Dekker E. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol 2006;101:343-

506. Pickhardt PJ, Hassan C, Halligan S, Marmo R. Colorectal cancer: CT colonography and colonoscopy for detection--systematic review and meta-analysis. Radiology 2011;259:393-405.

Model calibration results: Australia

Data sources:

• Bowel cancer incidence and mortality rate: AIHW 2015. Australian Cancer Incidence and Mortality (ACIM) books 2015

• Distribution of CRC in sections of bowel: Forman D, Bray F, Brewster DH et. al. (2013). Cancer Incidence in Five Continents, Vol. X (electronic version). Lyon: IARC. Available from: http://ci5.iarc.fr , accessed [03/02/2015].

• Stage distribution of symptomatically-detected and screen-detected CRC: Ananda SS, McLaughllin SJ, Chen F et al (2009). Initial impact of Australia’s National Bowel Cancer Screening Program. MJA 191(7):378-81

• 5-year survival of patient with symptomatically-detect4ed cancer: Morris M, Iacopetta B, Platell C (2007). Comparing survival outcomes for patients with colorectal cancer treated in public and private hospitals. MJA 186(6):296-300.

• Relative 5-year survival of screen-detected CRC patients vs. symptomatically-detected CRC: Gill MD, Bramble MG, Hull MA et al (2014). Screen-detected colorectal cancers are associated with an improved outcome compared with stage-matched interval cancers. BJC 111(11):2076-81

Baseline results: Fully rolled out NBCSP

Model predictions Overall estimated number in the period

over 2020-2035( 15 years)

Overall estimated number in the period

over 2015-2055 ( 40 years)

Estimated per annum number in the period over 2015-2055 ( 40

years)

# of bowel cancer deaths prevented 37,700 138,100 3,500

# of FOBT returned 30.5 million 85.4 million 2.1 million

# of individuals had a colonoscopy 2.0 million 5.6 million 140,000

# of individuals needed polypectomy 973,400 2.7 million 67,500

Cenin et al (2014) predicted over 2015-2055:

• A total of 70,000 deaths prevented. (equivalent to 1,750 deaths prevented p.a.)

• A total of 4.9 million colonoscopy (equivalent to 125,000 p.a.)

Reference:Cenin DR, St John DJ, Ledger MJ, Slevin T, Lansdorp-Vogelaar I. Optimising the expansion of the National Bowel Cancer Screening Program. Med J Aust 2014;201:456-61.

Conclusion• We have constructed a comprehensive platform for evaluation

of bowel cancer screening in Australia• In this initial evaluation, using the most recent data on age-

specific participation, we found that after the full implementation of the biennial screening program in 2020:– 138,100 lives would be saved in 2015-2055: 3,500 per year on average– 5.6 million individuals would undergo colonoscopy +/- polypectomy: 140,000

per year on average

• The biennial FOBT screening program is considered highly cost-effective when compared to a $50,000/life-years saved willingness-to-pay threshold in Australia.

Acknowledgement

This work was funded via:Australia Postgraduate Award (APA) PhD Scholarship for JBLTranslational Cancer Research Network (TCRN) Top-up scholarship, supported by Cancer Institute NSW for JBLPrince of Wales Clinical School/NHMRC PhD Scholarship for EHNHMRC Career Development Fellowship for KCAn initial seed funding grant from the Cancer Programs Division of Cancer Council NSWThe University of NSW, Australia