Gender and Race/Ethnicity Affect the Cost-Effectiveness of Colorectal Cancer Screening. RESULTS
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Table 2 and Table 3 list age-specific incidence rates of colorectal cancer in California from 1988-1995 for men and women, respectively, of each of four racial and ethnic groups. Age-specific colorectal cancer incidence rates were highest in black men and lowest in Latino women. For most ages between 45-85, the rank of incidence rates was consistent (black men > white men > Asian men > black women > white women > Latino men > Asian women > Latino women).
Table 2. Sampling of age-specific colorectal cancer incidence rates per 100,000 (and 95% CI) in men by race/ethnicity in California, 1988-1995
| Age | Asian | Black |
Latino |
White |
| 45 |
15.7 (9.9-23.5) |
22.3 (13.8-34.1) |
9.32 (6.20-13.5) |
17.4 (14.9-20.2) |
| 50 | 38.9 (28.0-52.6) | 51.3 (36.3-70.5) |
33.5 (26.2-42.2) |
37.6 (33.4-42.1) |
| 55 | 61.6 (46.1-80.5) |
103 (79.2-131) |
41.1 (31.9-52.3) |
74.0 (67.5-81.0) |
| 60 |
113 (89.1-140) |
170 (135-210) |
79.7 (65.3-96.3) |
137 (128-147) |
| 65 |
192 (159-230) |
263 (216-317) |
156 (134-182) |
219 (207-231) |
| 70 |
250 (208-300) |
330 (271-398) |
164 (136-196) |
296 (282-312) |
| 75 |
297 (241-362) |
402 (322-496) |
282 (235-337) |
406 (386-427) |
| 80 |
363 (287-455) |
537 (418-679) |
383 (314-464) |
531 (502-561) |
| 85 |
475 (350-630) |
594 (411-830) |
269 (193-365) |
603 (559-649) |
Table 3. Sampling of age-specific colorectal cancer incidence rates per 100,000 (and 95% CI) in women by race/ethnicity in California, 1988-1995
| Age |
Asian |
Black |
Latino |
White |
| 45 |
20.8 (14.4-29.1) |
23.9 (15.5-35.3) |
11.2 (770-] 57) |
14.6 (12.3-17.2) |
| 50 |
31.7 (22.3-43.7) |
61.4 (45.6-80.9) |
19.8 (14.3-26.6) |
28.8 (25.2-32.8) |
| 55 |
53.7 (40.1-70.4) |
75.0 (55.9-98.7) |
32.8 (24.9-42.5) |
56.5 (50.8-62.6) |
| 60 |
84.9 (66.6-106) |
115 (88.7-146) |
50.6 (39.9-63.4) |
87.5 (80.3-95.2) |
| 65 |
108 (86.7-134) |
144 (113-180) |
76.4 (62.0-93.1) |
144 (135-154) |
| 70 |
126 (100-157) |
227 (185-276) |
124 (102-148) |
204 (193-215) |
| 75 |
191 (151-238) |
310 (254-377) |
170 (139-205) |
275 (260-289) |
| 80 |
277 (215-352) |
423 (343-517) |
204 (165-250) |
362 (344-382) |
| 85 |
279 (191-394) |
429 (322-562) |
273 (214-345) |
440 (414-467) |
The utility and cost-effectiveness of flexible sigmoidoscopy are influenced by the percentage of colorectal cancers that are detectable with this test. Flexible sigmoidoscopy can reach 60 cm into the colon or to the splenic flexure. We analyzed California Cancer Registry data to determine the percent-age of colorectal cancers within men and women of each racial or ethnic group that occur at or distal to the splenic flexure and therefore could be detected by flexible sigmoidoscopy (Table 4). Within each race/ethnicity, men had a higher proportion of left-sided cancers. Both gender as well as race/ethnicity, however, affected the proportion of left-sided cancers (Asian men > Latino men > Asian women > white men > Latino women > black men > black women > white women). You can afford your medication buy your viagra jelly online
The cost-effectiveness of screening is influenced by the proportion of cancers that are detected without screening at an early stage. These cancers are more likely to be cured even without the benefits of early detection offered by screening. We analyzed California Cancer Registry data to determine the percentage of colorectal cancers within each racial and ethnic group that are diagnosed while still localized (node-negative) to the colon or rectum (Table 5). The proportion of localized disease was highest in white men and lowest in Latino women (38% vs. 33%). In general, men of each race/ethnicity had a slightly higher proportion of localized cancers compared to women. Levaquin 500 mg
We incorporated racial and ethnic differences in colorectal cancer incidence, the proportion of left-sided cancers and the proportion of early cancers to model the cost-effectiveness of colorectal cancer screening. We used two established strategies: 1) annual FOBT and every-five-years flexible sigmoidoscopy and 2) colonoscopy every 10 years, starting at age 50 and ending at age 85. These models also incorporated published differences in colorectal cancer survival and life expectancy between men and women of the four racial/ethnic groups. Assumptions underlying the model are summarized in Table 1.
Table 6. Cost-effectiveness estimates (cost per year of life saved) of a 35-year colorectal cancer screening program beginning at age 50 (or as noted) after adjusting for gender and racial/ethnic differences in colorectal cancer incidence, proportion of left-sided cancers, proportion of localized cancers, colorectal cancer survival and life expectancy
| Annual FOBT Plus Sigmoidoscopy Every Five Years | Colonoscopy Every 10 Years | |||
|
Five-Year |
10-Year |
Five-Year |
10-Year |
|
|
Polyp Dwell |
Polyp Dwell | Polyp Dwell | Polyp Dwell | |
| Men | ||||
| White |
$51,780 |
$47,817 |
$77,833 |
$41,530 |
| Black |
$39,776 |
$36,578 |
$43,532 |
$22,392 |
| Latino |
$82,239 |
$77,304 |
$124,903 |
$71,753 |
| Asian |
$61,671 |
$58,220 |
$99,305 |
$53,510 |
| Black (age 45) | $79,008 |
$42,383 |
||
| Black (age 40) | $114,961 |
$63,736 |
||
| Women | ||||
| White |
$70,843 |
$65,620 |
$106,422 |
$59,220 |
| Black |
$50,445 |
%A6,777 |
%72J65 |
$41,183 |
| Latino |
$120,941 |
$113,398 |
$187,453 |
$107,756 |
| Asian |
$92,897 |
$87,608 |
$143,271 |
$81,657 |
After adjusting for racial or ethnic differences in colorectal cancer, screening black men by either screening regimen was most cost-effective regardless of assuming a five- or 10-year polyp dwell time (the time it takes for a detectable polyp to become invasive cancer): black men > black women > white men > Asian men > white women > Latino men> Asian women > Latino women (Table 6). Cost-effectiveness ratios for black men were nearly half those of black women and white men and nearly one-fifth those of Latino women. Not surprisingly, sensitivity analyses indicated that cost-effectiveness estimates were largely (inversely) proportional to age-specific colorectal cancer incidence rates (data not shown). The superior life expectancy of women compared to men also had a significant impact by lowering cost-effectiveness ratios: since women live longer, they have more to gain by having colorectal cancer prevented or detected at a curable stage.Hence, the cost-effectiveness of black women was superior to that of white and Asian men despite the fact that black women had lower age-specific incidence rates. Although black male cost-effectiveness estimates were lowest of any group, their estimates would have been even lower had not the life expectancy estimates for black men been lower than that of the other groups.
These models assumed a similar polyp incidence among men and women of each racial and ethnic group. Polyp incidence data in racial and ethnic groups have not been reported. It is possible that a group with elevated colorectal cancer incidence may have a higher polyp incidence and that the percentage of polyps that become malignant is similar to that of other groups. Alternatively, the group may have a similar polyp incidence rate to that of other groups but a higher proportion of polyps may become malignant. To take into account the former possibility, we doubled the polyp incidence rate of black men. This adjustment resulted in a small change in cost-effectiveness. For example, using every- 10-years colonoscopic screening, the cost-effectiveness estimates for black men increased from $22,392 to $23,312 per year of life saved (10-year polyp dwell time). Cost-effectiveness estimates in men and women in the other racial and ethnic groups were also insensitive to changes in polyp incidence rate using both screening regimens (data not shown).
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We assessed the cost-effectiveness of a 35-year screening program in black men beginning at ages <50 to determine at what age cost-effectiveness estimates using colonoscopy exceeded the cost-effectiveness estimate of Latino women (the group in which screening was least cost-effective). We continued to adjust for the proportion of early cancers as well as colorectal cancer survival, life expectancy and colorectal cancer incidence using age-appropriate data. A 35-year screening program in black men beginning at age 40 (five-year polyp dwell time: $114,961 per year of life saved; 10-year polyp dwell time: $63,736 per year of life saved) was similar in cost-effectiveness to a 35-year screening program in white women beginning at age 50 and more cost-effective than 35-year screening programs in Latino men, Asian women and Latino women beginning at age 50. This was true even after doubling the polyp incidence rate in black men (data not shown). Furthermore, a 35-year screening program in black men beginning at age 45 (five-year polyp dwell time: $79,008 per year of life saved; 10-year polyp dwell time: $42,383 per year of life saved) was similar in cost-effectiveness to 35-year screening programs in white men and black women beginning at age 50 and more cost-effective than 35-year screening programs in Latino and Asian men as well as nonblack women. This was true even after doubling the polyp incidence rate in black men (data not shown).
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