Cost-Effectiveness and National Effects of Initiating Colorectal Cancer Screening for Average-Risk Persons at Age 45 Years Instead of 50 Years

Gastroenterology. 2019 Jul;157(1):137-148. doi: 10.1053/j.gastro.2019.03.023. Epub 2019 Mar 28.


Background & aims: The American Cancer Society has recommended initiating colorectal cancer (CRC) screening at age 45 years instead of 50 years. We estimated the cost effectiveness and national effects of adopting this recommendation.

Methods: We compared screening strategies and alternative resource allocations in a validated Markov model. We based national projections on screening participation rates by age and census data.

Results: Screening colonoscopy initiation at age 45 years instead of 50 years in 1000 persons averted 4 CRCs and 2 CRC deaths, gained 14 quality-adjusted life-years (QALYs), cost $33,900/QALY gained, and required 758 additional colonoscopies. These 758 colonoscopies could instead be used to screen 231 currently unscreened 55-year-old persons or 342 currently unscreened 65-year-old persons, through age 75 years. These alternatives averted 13-14 CRC cases and 6-7 CRC deaths and gained 27-28 discounted QALYs while saving $163,700-$445,800. Improving colonoscopy completion rates after abnormal results from a fecal immunochemical test yielded greater benefits and savings. Initiation of fecal immunochemical testing at age 45 years instead of 50 years cost $7700/QALY gained. Shifting current age-specific screening rates to 5 years earlier could avert 29,400 CRC cases and 11,100 CRC deaths over the next 5 years but would require 10.7 million additional colonoscopies and cost an incremental $10.4 billion. Improving screening rates to 80% in persons who are 50-75 years old would avert nearly 3-fold more CRC deaths at one third the incremental cost.

Conclusions: In a Markov model analysis, we found that starting CRC screening at age 45 years is likely to be cost effective. However, greater benefit, at lower cost, could be achieved by increasing participation rates for unscreened older and higher-risk persons.

Keywords: Colon Cancer; Cost-Effectiveness; Prevention; Screening.

MeSH terms

  • Age Factors
  • Aged
  • American Cancer Society
  • Colonoscopy / economics
  • Colonoscopy / methods*
  • Colorectal Neoplasms / diagnosis*
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Early Detection of Cancer / economics
  • Early Detection of Cancer / methods*
  • Female
  • Humans
  • Immunochemistry / economics
  • Immunochemistry / methods
  • Male
  • Markov Chains
  • Middle Aged
  • Occult Blood*
  • Practice Guidelines as Topic
  • Quality-Adjusted Life Years
  • United States