Prevention and Treatment of Colorectal Cancer: Pay Now or Pay Later

• Colorectal neoplasms
• Colonoscopy
• Sigmoidoscopy
• Occult blood
• Adenomatous polyposis coli

Colorectal cancer, the second most common cause of cancer-related death in the United States (1), is well suited for prevention with screening programs. It has a high incidence, is fatal when diagnosed at an advanced stage, is curable when diagnosed at early stages, and passes through a detectable asymptomatic stage; moreover, screening tests with varying degrees of sensitivity and specificity are readily available.

The basic principle underlying colorectal cancer screening programs is that removal of precancerous adenomatous polyps prevents the development of most colorectal cancers (2). In addition, identification of colorectal cancer at an early stage allows for cure of most patients, whereas few cancers can be cured after distant metastases appear (1).

The two most widely used screening tests are fecal occult blood testing and flexible sigmoidoscopy. All persons with positive results on these two screening tests are recommended to undergo colonoscopy for identification and removal of adenomatous polyps and cancers. Well-designed randomized, controlled trials and case–control studies provide convincing evidence of the efficacy of fecal occult blood testing and flexible sigmoidoscopy (3-8). However, both screening strategies are limited by poor rates of compliance (9) and are less sensitive than colonoscopy (10). As a result, there is growing interest in colonoscopy as a primary screening test for average-risk patients. Two recent studies demonstrated the feasibility of such programs (11, 12). It now appears almost certain that screening colonoscopy can effectively reduce colorectal cancer–related mortality and is most likely more effective than fecal occult blood testing, flexible sigmoidoscopy, or a combination of the two. However, an important question that remains is how much this strategy will cost.

Sonnenberg and colleagues (13) attempted to answer this question by performing a cost-effectiveness analysis …