# Presentation: 782479

## Decision Analysis of Colorectal Cancer Screening Tests by Age to Begin, Age to End, and Screening Intervals:Report to the United States Preventive Services Task Force from the Cancer Intervention and Surveillance Modeling Network (CISNET)Agency for Healthcare Quality and ResearchSeptember 8, 2008

**MISCAN**
**Memorial Sloan-Kettering Cancer Center  *****-Ann Zauber              ***
**Erasmus MC  - *****Marjolein van Ballegooijen, Iris Lansdorp-Vogelaar, Janneke Wilschut***

**SimCRC**
**University of Minnesota – *****Karen Kuntz***
** ****Massachusetts General Hospital – *****Amy Knudsen***

**Notes:**
It is a real privilege to have the opportunity to present to you today. The USPSTF guidelines have a huge impact in facilitating colorectal cancer screening. 

I am pleased to discuss with you today a decision analysis of colorectal cancer screening tests by age to begin, age to end, and screening intervals. 

Thank you, Mary, for the very nice introduction to decision analysis.

This report is from the NCI Cancer Intervention and Surveillance Modeling NETWORK – Called CISNET  Our logo is here –and it represents putting together the various influences on changes in incidence and mortality. 

This work is from two colorectal cancer modeling groups.

MISCAN – microsimulation modeling for screening in cancer – is a model developed by Erasmus in Rotterdam. Our CISNET group  is a collaboration between Memorial Sloan Kettering Cancer Center where I am and Erasmus  with Marjolein van Ballegooijen, Iris Lansdorp-Vogelaar, and Janneke Wilschut.

SimCRC – simulated colorectal cancer .- is a model developed by Karen Kuntz (who is joining us on the line) . Karen has recently moved from Harvard to the University of Minnesota.  Amy Knudsen now at  Mass General Hospital has also contributed to this report.

Our two groups have been working AHRQ – Mary Barton, Bill Lawrence, Elise Berliner, and Chuck Shih.

I just found out last week that is was Abraham Lincoln who initiated having scientific support for policy makers. Lincoln established the National Academy of Sciences to give  scientific advice to his health policy makers.

## What CMS reimbursement for a new CRC test?         2003 and 2007

**Stool DNA test?**

**$ to be determined**

- $4.54

- $22.22

**National Coverage Determination (NCD) on stool DNA (PreGen-Plus test, version 1.1 **_**every 5 years**_** for average risk population)**

**Notes:**
The CISNET modelers started working with AHRQ in 2003.

## Questions addressed by CISNET for USPSTF 2007 

- USPSTF addresses updates for 2002 colorectal cancer screening recommendations
- Evidence based literature review
- Task Force requested a decision analysis for recommended CRC screening tests for
- age to begin
- age to end
- rescreening interval
*Should the current recommendations be changed?*
- Microsimulation models (MISCAN and SimCRC) of CISNET consortium used for the decision analysis *to inform health policy *

## Adenoma to Carcinoma Pathway

**Normal**
**Epithelium**

**Small**
**Adenoma**

**Colorectal**
**Cancer**

**Advanced**
**Adenoma**

**Notes:**
Polyp removal leads to CRC prevention
Polyp is surrogate marker

The adenoma is the precursor lesion for colorectal cancer. 
We will describe a mathematical model for the  adenoma carcinoma 
Sequence from normal epithelium to small adenoma to advanced 
Adenoma to invasive colorectal cancer

## Microsimulation Modeling of Adenoma Carcinoma Sequence with Potential Interventions

**adenoma**
**6-9 mm**
**adenoma**
**>=10 mm**

_**ADENOMA**_
**Preclinical**
**screen-detectable adenoma phase**

**No lesion**

**adenoma**
**<=5 mm**

_**Preclinical**_
_**CANCER**_
**screen-detectable**
**cancer phase**

**clinical**
**stage I**
**clinical**
**stage II**
**clinical**
**stage III**
**clinical**
**stage IV**

_**Clinical**_
_**CANCER**_
**phase**

**death**
**colorectal**
**cancer**

**Datasources:**

**Adenoma**
- Autopsy studies
- Colonoscopy studies

**Preclinical Cancer**
- Dwell time

**Clinical Cancer**
- SEER Incidence

**Death**
- US Mortality

**Notes:**
In our microsimulation models we represent the adenoma carcinoma sequence as a series of stages from no adenoma, adenoma by size, preclinical disease, clinical disease, and  death due to  colorectal cancer. 

An individual is at risk by age and sex to develop one or more adenomas.
If an adenoma forms, then some grow larger and become more advanced. Some of these can PROGRESS into preclinical cancers and clinical cancers. Some of these can cause death from colorectal cancer.

The adenoma-carcinoma sequence can be affected by risk factors, screening and chemotherapy.
Risk factors can affect the risk of developing adenomas
Screening can affect colorectal cancer incidence and mortality by interrupting  the adenoma carcinoma sequence by detecting and removing adenomas or detecting CRC at an earlier stage.

Chemotherapy can reduce colorectal cancer deaths in those who have developed CRC.

We simulate a population of 40 years old (born 1965) in 2005 in the US population. Some will develop no adenomas; some will have developed 1 or more adenomas, some will die of colorectal cancer, and some will die of other causes.

## Colorectal Cancer Screening StrategiesCurrent Age and Interval Recommendations*

- Age Begin

- 50

- Screening Tests

- Hemoccult II
- Hemoccult SENSA
- FIT
- Flex Sig
- Flex Sig + SENSA
- Colonoscopy

- Rescreening Intervals

-  1 – FOBT
-  5 – Flex Sig
- 10 - Colonoscopy

- Age End

- None

- Surveillance

- No stop age

- * MultiSociety and ACS

**Notes:**

Age begin is 50
No age to end

Rescreening intervals for annual FOBT and 5 for flex sig and10 for colonoscopy

## Colorectal Cancer Screening StrategiesCohort of 40 year olds in 2005

- Age Begin

- 40
- 50
- 60

- Screening Tests

- Hemoccult II
- Hemoccult SENSA
- FIT
- Flex Sig*
- Flex Sig* + SENSA
- Colonoscopy
- (No Screening)

- * *With biopsy*

- Rescreening Intervals

- 1,2,3 – FOBT
- 5,10,20- Endos

- Age End

- 75
- 85

- Surveillance**

- No stop age

- Adherence 100%

- ** *3 year for advanced adenomas, 5-10 (5) for non-advanced adenomas*

- 145 Test Strategies

**Notes:**
For the decision analysis we consider different colorectal cancer screening strategies in a cohort of 40 year olds in the US in 2005

We consider the screening tests of 
Hemoccult SENSA – this is the more sensitivity guaiac test compared to the Hemoccult II test used in the RCT’s re mortality
Fecal immunochemical  test( FIT)  or immunochemical fecal occult blood test.
	This test  selects for human hemoglobin in stool
	Several different FIT’s on the market – past and present with different test parameters

Flexible sigmoidoscopy – with biopsy of lesions and those with adenomas are referred on for colonoscopy
Colonoscopy

We also consider the strategy of no screening

We consider 3 ages to begin screening in asymptomatic persons
	Age 40, 50 and 60

Rescreening interval of 1,2 or 3 years between FOBT tests, and 5.10. or 20 years between flex sig or colonoscopy screenings.

Stop ages of 75or 85

Surveillance for those with adenomas of CRC detected does not have an ending age.

NOTE that we assume there is 100% compliance with initial and repeat screening tests and with diagnostic evaluation of positive tests.

## Sensitivity and Specificity of Testsfrom Literature Review

_**>**_**10mm**

**6-9mm**

_**<**_**5mm**

**CRC Sensitivity**

**Specificity**

- Percent

- Percent

- Hemoccult II

- Hemoccult SENSA

- FIT

- Sigmoidoscopy

- Sig + Hemoccult SENSA

- Colonoscopy

**Adenoma Sensitivity by Size**

**Sensitivity and Specificity of Tests****from Literature Review**

- Sigmoidoscopy sensitivity for lesions within range

## Screening Test Costs $ per Test

**Screening Test Costs ****$ per Test**

**4.54**

**4.54**

**22.22**

**161**

**498**

**649**

*USPSTF requested NOT to use costs*

## Outcome Measures

- Most effective = Greatest life years gained relative to no screening
- Weigh effectiveness *against *                                      resources required and exposure to risks:     *Colonoscopy as resource and risk indicator*
- Endoscopy resources
- Perforation risk
- Life years gained (LYG) vs                                              Total colonoscopies in lifetime
*	**(per 1000 persons in population)*
*.*

**Notes:**
What outcome measures do you use?

We first look to see what strategies are the most effective – ie greater life years gained relative to no screening.

Next we weigh the effectiveness against the resources required and the exposure to risks of procedures associated with screening.
We use colonoscopic resources as our indicator for endoscopy resources required and for exposure to risk of perforation.

We will use life yeas gained (LYG) as indicator of benefit or effectiveness and 
Total colonoscopies in lifetime per 1000 persons in the population as our indication for benefit and risks.

## Effectiveness-Risk Analysis

- Determine efficient strategies for each test
*Plot life years gained versus colonoscopies required*
- If strategy requires more colonoscopies but has fewer life years gained (LYG) *(**ie less effective**)* then eliminate
- Of the remaining strategies, rank by increasing effectiveness (LYG) Derive relative to each other:
- Incremental number of colonoscopies = ΔCol
- Incremental LYG = ΔLYG
- Incremental number colonoscopies to gain a life yr = ΔCol/ ΔLYG
- Efficiency Ratio of measure of the *additional* number of colonoscopies required to gain one year of benefit when considering a more effective strategy relative to the next less effective strategy
- Efficiency frontier – all strategies NOT dominated (eliminated)
- Near the efficiency frontier – those strategies that are with 98% of the LYG on the frontier

**Notes:**
We have 145 strategies  to evaluate. We are using the algorithm presented here to identify effective strategies to consider.

If a strategy requires more colonoscopies but gives fewer life years gained than other strategies, then it is eliminated from consideration as a recommended strategy.  Mary showed this in her table. (AZ check table!) Get less –requires more – eliminate!  
Of the remaining strategies, derive comparison of each strategy relative to all others remaining.
If the life years gained is less relative and the ratio of resources to life years gained is higher than another strategy then this strategy is eliminated due to extended dominance.   Less gain with a higher incremental use of resources and risk compared to another strategy.

The strategies which are NOT dominated by another form the efficient frontier – as Mary presented.- the red line.

For our analyses we also considered strategies that are within 98% of the life years gained on the frontier.

## Colonoscopy-MISCAN

## Colonoscopy-SimCRC

## Efficient Colonoscopy Strategies

| Strategy* |  | # Col
(per 1000) | # LYG
(per 1000) | Col
(per 1000) | LYG
(per 1000) | Col/LYG |
| --- | --- | --- | --- | --- | --- | --- |
| MISCAN |  |  |  |  |  |  |
| 1 | COL, 60-75, 20 | 2,175 | 156 |  |  | --- |
| 2 | COL, 50-75, 20 | 3,325 | 203 | 1,150 | 47 | 24.7 |
| 3 | COL, 50-75, 10 | 4,136 | 230 | 811 | 27 | 29.6 |
| 4 | COL, 50-85, 10 | 4,534 | 236 | 398 | 5 | 72.9 |
| 5 | COL, 50-75, 5 | 5,895 | 254 | 1,362 | 18 | 74.8 |
| 6 | COL, 50-85, 5 | 6,460 | 257 | 565 | 4 | 156.1 |
| SimCRC |  |  |  |  |  |  |
| 1 | COL, 60-75, 20 | 1,780 | 165 |  |  | --- |
| 2 | COL, 50-75, 20 | 2,885 | 246 | 1,106 | 82 | 13.5 |
| 3 | COL, 50-75, 10 | 3,756 | 271 | 871 | 25 | 34.7 |
| 4 | COL, 50-85, 10 | 4,114 | 273 | 358 |   2 | Dominated |
| 5 | COL, 50-75, 5 | 5,572 | 281.6 | 1,816 | 10 | 178.8 |
| 6 | COL, 50-85, 5 | 6,031 | 282 | 459 | 0.5 | 975.7 |
| * Test, begin age – end age, interval
Col = incremental number of colonoscopies compared with the next best strategy
LYG = incremental number of life years gained compared with the next best strategy |  |  |  |  |  |  |

**Notes:**
In Table 3 we have the efficient or near efficient colonoscopy strategies for the start ages of 50 and 60. For both MISCAN and SimCRC there were 6 efficient strategies  out of 12 possible.
 The current guidelines strategy is given in the blue line and is beginning colonoscopy screening at age 50 and ending screening at age 85 with 10 years between screenings. So screening at age 50,60,70,80 or 4 colonoscopies.

The term col,60-75,20 means that the strategy begins screening at age 60 and ends at age 75 and has a 20 year wait between screenings. This actually becomes a 1 time screening at age 60 because the second screen would be at age 80 and we stop screening at age 75 for this strategy.

The 3rd column is the number of colonoscopies per 1000 persons for this strategy
The 4th column is the number of life years gained relative to no screening.

The ordering of the strategies by life years gained is the same for MISCAN and for SimCRC but LYG is greater for SImCRC than for MISCAN. As noted we expected that because of the shorter dwell time for MISCAN relative to SimCRC.  

The 4th column is the difference in colonoscopies required for that strategy relative to the strategy preceding ;
 Column 5 is the difference in LGY for this strategy relative to the preceding efficient strategy.  The last column is the efficiency ratio which is the additional number of colonoscopies required to gain one year of benefit when considering a more effective strategy relative to the next less effective strategy
Note that the difference in stopping screening at age 75 rather than 85 with 10 year rescreening colonoscopy has only a difference of 4 life years gained but a difference of 446 per 1000 colonoscopies (MISCAN). For SimCRC this same strategy has exactly the same number of lifeyears gained with stopping at age 75 vs 85 but with a life years gained are the same but resources are much greater for stopping at age 85 than 75.  

There was a typo in the table – the blue row for MISCAN should have an incremental difference of 5 years not 4.

Note from Karen.: Even thought the COL, 50-85, 10 strategy is dominated using SimCRC we know that the efficiency ratio (compared with COL, 50-75, 10) is > 371.3 (eg, very high compared with the ratio for stop age of 75).

## Age to End Screening

- No prior recommendations on stop age for CRC screening
- Age 75 and 85 considered
- Comorbidity and life expectancy rather than chronological age important
- Example for colonoscopy:                                                 If start screening at age 50 and stop at age 75
- Negative colonoscopy at age 50, 60, and 70
- 3 negative exams before stopping
- Those with adenomas or colorectal cancer detected at screening colonoscopy would be in a surveillance program with no stopping age

## Hemoccult II-MISCAN

## Hemoccult SENSA-MISCAN

## FIT-MISCAN

## Flexible Sigmoidoscopy-MISCAN

## Combination-MISCAN

## Comparisons Among Testswithout comparator of costs

- To compare among tests, it is important to consider that tests other than colonoscopy are required (ie, FOBT, Flex Sig)
- To pick an efficient strategy for each test we would expect to find an ordering to the efficiency ratios as follows:
- COL > SENSA > [FIT, HII] > [FSig, FSig+SENSA]
- Eg, SENSA should require *fewer* colonoscopies to gain a benefit of 1 year compared with COL because of the added number of FOBTs needed in addition to the colonoscopies to achieve that benefit.

**Notes:**
Note on last bullet from Karen.  Otherwise SENSA would be considered a resource-intensive strategy.  
The strategies are ordered by the burden of testing.  Colonoscopy would have the fewest test points and flex sig plus SENSA would potentially have the most  test points.

## Approach to ChoosingEfficient Strategies

- Assume that a single start and end age would be recommended for screening
- Select strategies from all tests (including combination of tests) that:
- are efficient (or near efficient) within the test
- have efficiency ratios with expected ordering (to account for the burden of other testing)
- have comparable effectiveness (LYG)
- Example: start age = 50; stop age = 75; anchored with 10-year colonoscopy (as a starting strategy)

## Efficient (near efficient) strategies for start age 50 and stop age 75-(Table 9 bolded strategies)

| Strategy* | # Col
(per 1000) | # LYG
(per 1000) | Col/
LYG | 
# FOBT |  | 
# Fsig |
| --- | --- | --- | --- | --- | --- | --- |
| MISCAN |  |  |  |  |  |  |
| COL, 50-75, 10 | 4,136 | 230 | 29.6 | 0 |  | 0 |
| SENSA®, 50-75, 1 | 3,350 | 230 | 30.9 | 9,541 |  | 0 |
| FIT, 50-75, 1 | 2,949 | 227 | 25.9 | 11,772 |  | 0 |
| Hem II®, 50-75, 1 | 1,982 | 194 | 14.3 | 16,232 |  | 0 |
| Fsig, 50-75, 5 | 1,911 | 203 | 9.7 | 0 |  | 4,139 |
| FsigSENSA®, 50-75, 5,3 | 2,870 | 230 | 16.3 |  | 6,145 |  |
| SimCRC |  |  |  |  |  |  |
| COL, 50-75, 10 | 3,756 | 271 | 34.7 | 0 |  | 0 |
| SENSA®, 50-75,1  | 2,654 | 259 | 22.9 | 9,573 |  | 0 |
| FIT, 50-75,1  | 2,295 | 256 | 19.7 | 11,830 |  | 0 |
| Hem II®, 50-75, 1  | 1,456 | 218 | 9.6 | 16,239 |  | 0 |
| Fsig, 50-75, 5 | 995 | 199 | 8.4 | 0 |  | 4,483 |
| FsigSENSA®, 50-75, 5,3 | 1,655 | 257 | 7.0 |  | 9,679 |  |

## Sensitivity Analysis

- Comparative modeling (2 models) give similar results
- Similar rankings of strategies even if assume better or worse estimates on sensitivity and specificity
- Adherence varied from 100%, 80%, 50%

## MISCAN Adherence Plot

## CONCLUSIONS 

- Current recommended guidelines* are on or close to the efficiency frontier
- Beginning at age 50 balances life years gained and number of colonoscopies required and associated risk of perforation
- To increase efficiency of current guidelines*, stop screening at age 75
*should depend on life expectancy of person rather than strict chronological age*

- *MultiSociety and ACS

## CONCLUSIONS  (Continued 1)

- Annual SENSA or FIT have similar LYG as colonoscopy every 10 years but with lower colonoscopy requirements – *PROVIDED high compliance for all tests*
- FlexSig every 5 years with annual FOBT with Sensitive FOBT not recommended (high efficiency ratio)
- Original strategy for Flex Sig+ FOBT was for Hemoccult II with lower sensitivity
- Combination of Flex Sig and Hemoccult SENSA® could have one mid-interval FOBT between the 5 year repeat Flex Sig screening rather than annual FOBT
- FlexSig every 5 years and Hemoccult II not as good in terms of effectiveness

## CONCLUSIONS for Adherence

- Adherence conclusions
- Life years gained and colonoscopies decreased with decreased adherence BUT
- The overall conclusions did not change substantially as adherence varied from 50% to 100%.
- Hemoccult II and flexible sigmoidoscopy every 5 years remained the least two attractive alternatives re life years gained
- Colonoscopy every 10 years improved a bit relative to the other strategies when adherence was 80% but lost its health benefit advantage when adherence as 50%

## Limitations

- Analyses for whole population – not specific by sex or race
- Potential of more proximal disease in older women and blacks
- Age of onset may vary by sex and race
- Inadequate data on adenoma prevalence age 40
- Chronological age rather than life expectancy
- Life expectancy of men:  10.5 at age 75 and 5.9 at 85
- Life expectancy of women:  12.5 at age 75 and 7.0 at 85
- Simulation models rely on assumptions of natural history of disease
- Comparing two models provides sensitivity analysis  of natural history assumptions

## ‘Best’ Test is the One Which Gets Done- SJ Winawer re Adherence

## Slide 31

**Thank You**

**Mary Barton, William Lawrence  of  AHRQ**
**Diana Pettit, Michael LeFevre, George Isham, and Steve Teutsch of USPSTF**

**Acknowledgements**

## Screening and Treatment Costs by Screening Strategy

- Hemoccult II

- Hemoccult SENSA

- FIT

- No Screening

- Sigmoidoscopy

- Sig + Hemoccult SENSA

- Colonoscopy

- Per  1000 screened

**Notes:**
The title confused me as it was before.

## Components of Screening Costs  (per 1000 screened)  (CMS analysis age 65+)

- Hemoccult II

**Screening Test**

**Polyp Resection and Pathology**

**Follow-up of Positive Test**

**Surveillance**

**Complications**

- Hemoccult SENSA

- FIT

- Sigmoidoscopy

- Sig + Hemoccult SENSA

- Colonoscopy

**Components of Screening Costs  ****(per 1000 screened)  *****(CMS analysis age 65+)***

**Notes:**
The components of non-treatment costs are shown here.  Screening and surveillance costs are the primary drivers of the non-treatment costs. Polyp resection and pathology, follow-up, and even complication costs are much lower contributors to screening non-treatment costs.

The non-treatment costs are unlikely to increase with higher reimbursements over time. 

## Model Calibrations

- Process of matching model output with data
- Useful when data aren’t available to estimate certain model parameters but are available on model outcomes
- Compare model output with empirical data
- Prevalence and number of adenomas
- 	(autopsy studies)
- Location and size of lesions
- 	(colonoscopy studies)
- Incidence, location, and stage of diagnosed CRC
- 	(SEER)

**Notes:**
An important component of microsimulaiton modeling is to ensure that the model replicates the real data. This process is model calibration.

We use a process to match the model output with observed data.

This is particularly useful when data are not available to estimate certain inputs (model parameters) but where we do have real data on the outcomes to be predicted by the model – such as incidence and mortality

We compare our model output with empirical data
We use prevalence and number of adenomas from autopsy studies to derive estimates for the transition probabilities to develop an adenoma and for the adenoma to progress to colorectal cancer.

We can use location and size of adenomas from screening colonoscopy studies to distribute the adenomas by location and size in the colon.

We adjust the probability of developing an adenoma or of an adenoma progressing in size to reflect the incidence. location, and stage of CRC as given in SEER.  This is called model calibration.

## SENSA®, 50-75,1   

**Specificity of  92.5% (base case) vs 87% (ER)**
**Colonoscopy 50-75,10 given as comparator**

| Strategy             MISCAN | # Col (per 1000) | # LYG (per 1000) |
| --- | --- | --- |
| Colonoscopy, 50-75, 10 | 4,136 | 230 |
| SENSA®, 50-75,1 (basecase) | 3,350 | 230 |
| SENSA®, 50-75,1 (SA at 87% specificity) | 3,832  (+14%) | 233     (+1%) |

| Strategy          SimCRC |   # Col (per 1000) | # LYG (per 1000) |
| --- | --- | --- |
| Colonoscopy, 50-75, 10  | 3,756 | 271 |
| SENSA®, 50-75,1 (basecase) | 2,654 | 259 |
| SENSA®, 50-75,1 (SA at 87% specificity) | 3,104   (+17%) | 263    (+1.5%) |

## Efficient Strategiesfor start age of 50 and stop age of 75(Table 9 Page 31)

| Strategy* | # Col
(per 1000) | # LYG
(per 1000) | Col
(per 1000) | LYG
(per 1000) | Col/LYG |
| --- | --- | --- | --- | --- | --- |
| MISCAN |  |  |  |  |  |
| COL, 50-75, 10 | 4,136 | 230 | 811 | 27 | 29.6 |
| SENSA®, 50-75, 1 | 3,350 | 230 | 766 | 25 | 30.9 |
| FIT, 50-75, 1 | 2,949 | 227 | 765 | 30 | 25.9 |
| Hem II®, 50-75, 1 | 1,982 | 194 | 647 | 45 | 14.3 |
| Fsig, 50-75, 5 | 1,911 | 203 | 864 | 89 | 9.7 |
| FsigSENSA®, 50-75, 5,3 | 2,870 | 230 | 839 | 52 | 16.3 |
| SimCRC |  |  |  |  |  |
| COL, 50-75, 10 | 3,756 | 271 | 871 | 25 | 34.7 |
| SENSA®, 50-75,1  | 2,654 | 259 | 698 | 31 | 22.9 |
| FIT, 50-75,1  | 2,295 | 256 | 681 | 35 | 19.7 |
| Hem II®, 50-75, 1  | 1,456 | 218 | 536 | 56 | 9.6 |
| Fsig, 50-75, 5 | 995 | 199 | 187 | 22 | 8.4 |
| FsigSENSA®, 50-75, 5,3 | 1,655 | 257 | 611 | 88 | 7.0 |
| * Test, begin age – end age, interval     Col = incremental number of colonoscopies compared with the next best strategy
LYG = incremental number of life years gained compared with the next best strategy |  |  |  |  |  |

**Notes:**
Show the 75 vs 85 differences here also
Life years saved is lower than other strategies.

## Efficient Strategiesfor start age of 50 and stop age of 75Rank order of strategies

| Strategy* | # Col
(per 1000) | # LYG
(per 1000) | Col/LYG |
| --- | --- | --- | --- |
| MISCAN |  |  |  |
| COL, 50-75, 10 | 4,136 (1) | 230 (1) | 29.6 |
| SENSA®, 50-75, 1 | 3,350 (2) | 230 (1) | 30.9 |
| FIT, 50-75, 1 | 2,949 (3) | 227 (4) | 25.9 |
| Hem II®, 50-75, 1 | 1,982 (5) | 194 (6) | 14.3 |
| Fsig, 50-75, 5 | 1,911 (6) | 203 (5) | 9.7 |
| FsigSENSA®, 50-75, 5,3 | 2,870 (4) | 230 (1) | 16.3 |
| SimCRC |  |  |  |
| COL, 50-75, 10 | 3,756 (1) | 271 (1) | 34.7 |
| SENSA®, 50-75,1  | 2,654 (2) | 259 (2) | 22.9 |
| FIT, 50-75,1  | 2,295 (3) | 256 (4) | 19.7 |
| Hem II®, 50-75, 1  | 1,456 (5) | 218 (5) | 9.6 |
| Fsig, 50-75, 5 |     995 (6) | 199 (6) | 8.4 |
| FsigSENSA®, 50-75, 5,3 | 1,655 (4) | 257 (3) | 7.0 |
| * Test, begin age – end age, interval     Col = incremental number of colonoscopies compared with the next best strategy
LYG = incremental number of life years gained compared with the next best strategy |  |  |  |

**Notes:**
Show the 75 vs 85 differences here also
Life years saved is lower than other strategies.

## Comparisons 

- First  compare strategies within a screening test
- Efficient frontier derived for each screening test or combination test
- Col/LYG – ‘Efficiency Ratio’
- A measure of the *additional* number of colonoscopies required to gain one year of benefit when considering a more effective strategy relative to the next less effective strategy
- Colonoscopy resources across tests are comparable but burden of *all testing* is not

**Notes:**
.
First we compare the strategies within a screening test.

Use the wording of the slide.

GO SLOWLY HERE