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. 2021 Sep;14(9):845-850.
doi: 10.1158/1940-6207.CAPR-21-0075. Epub 2021 May 21.

Impact of Patient Adherence to Stool-Based Colorectal Cancer Screening and Colonoscopy Following a Positive Test on Clinical Outcomes

A Mark Fendrick  1   2 , Deborah A Fisher  3 , Leila Saoud  4 , A Burak Ozbay  4 , Jordan J Karlitz  5 , Paul J Limburg  6
Affiliations

Impact of Patient Adherence to Stool-Based Colorectal Cancer Screening and Colonoscopy Following a Positive Test on Clinical Outcomes

A Mark Fendrick et al. Cancer Prev Res (Phila). 2021 Sep.

Abstract

Colorectal cancer-screening models commonly assume 100% adherence, which is inconsistent with real-world experience. The influence of adherence to initial stool-based screening [fecal immunochemical test (FIT), multitarget stool DNA (mt-sDNA)] and follow-up colonoscopy (after a positive stool test) on colorectal cancer outcomes was modeled using the Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model. Average-risk individuals without diagnosed colorectal cancer at age 40 undergoing annual FIT or triennial mt-sDNA screening from ages 50 to 75 were simulated. Primary analyses incorporated published mt-sDNA (71%) or FIT (43%) screening adherence, with follow-up colonoscopy adherence ranging from 40% to 100%. Secondary analyses simulated 100% adherence for stool-based screening and colonoscopy follow-up (S1), published adherence for stool-based screening with 100% adherence to colonoscopy follow-up (S2), and published adherence for both stool-based screening and colonoscopy follow-up after positive mt-sDNA (73%) or FIT (47%; S3). Outcomes were life-years gained (LYG) and colorectal cancer incidence and mortality reductions (per 1,000 individuals) versus no screening. Adherence to colonoscopy follow-up after FIT had to be 4%-13% higher than mt-sDNA to reach equivalent LYG. The theoretical S1 favored FIT versus mt-sDNA (LYG 316 vs. 297; colorectal cancer incidence reduction 68% vs. 64%; colorectal cancer mortality reduction 76% vs. 72%). The more realistic S2 and S3 favored mt-sDNA versus FIT (S2: LYG 284 vs. 245, colorectal cancer incidence reduction 61% vs. 50%, colorectal cancer mortality reduction 69% vs. 59%; S3: LYG 203 vs. 113, colorectal cancer incidence reduction 43% vs. 23%, colorectal cancer mortality reduction 49% vs. 27%, respectively). Incorporating realistic adherence rates for colorectal cancer screening influences modeled outcomes and should be considered when assessing comparative effectiveness. PREVENTION RELEVANCE: Adherence rates for initial colorectal cancer screening by FIT or mt-sDNA and for colonoscopy follow-up of a positive initial test influence the comparative effectiveness of these screening strategies. Using adherence rates based on published data for stool-based testing and colonoscopy follow-up yielded superior outcomes with an mt-sDNA versus FIT-screening strategy.

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Conflict of interest statement

A.M. Fendrick reports other support and has been a consultant for AbbVie, Amgen, Bayer, Centivo, Community Oncology Association, Covered California, EmblemHealth, Exact Sciences, Freedman, Health, GRAIL, Harvard University, Health and Wellness, Innovations*, Health at Scale Technologies*, HealthCorum, Hygieia, MedZed, Merck, Montana, Health Cooperative, Pair Team*, Penguin Pay, Phathom Pharmaceuticals, Risalto, Risk International, Sempre Health*, State of Minnesota, U.S., Department of Defense, Virginia Center for Health, Innovation, Wellth*, Wildflower Health, Yale-New Haven Health System, Zansors*, as well as equity Interest Research: AHRQ, Boehringer-Ingelheim, Gary and Mary West Health Policy Center, Arnold Ventures, National Pharmaceutical Council, PCORI, PhRMA, RWJ Foundation, State of Michigan/CMS Outside Position: AJMC (Co-editor), ME. D.A. Fisher reports grants and other support from Exact Sciences during the conduct of the study; as well as other support from Guardant Health outside the submitted work. L. Saoud reports personal fees from Exact Sciences during the conduct of the study. A. Ozbay reports other support from Exact Sciences during the conduct of the study; as well as other support from Exact Sciences outside the submitted work. J.J. Karlitz reports personal fees from Exact Sciences and other support from Gastro Girl/GI OnDemand outside the submitted work. P.J. Limburg reports other support from Exact Sciences during the conduct of the study; as well as other support from Exact Sciences outside the submitted work.

Figures

Figure 1.
Figure 1.
Equal predicted life years-gained (LYG) for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) by the follow-up colonoscopy adherence rate. Circles indicate equivalent LYG when adherence to initial mt-sDNA and FIT screening is assumed to be 71% and 43%, respectively. Squares indicate equivalent LYG when adherence to initial mt-sDNA and FIT screening is assumed to be 71% and 48.2%, respectively (sensitivity analysis).
Figure 2.
Figure 2.
A, Predicted life years-gained (LYG). B, Colorectal cancer incidence and mortality reduction for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) in 3 different adherence scenarios. Results are per 1,000 individuals free of diagnosed colorectal cancer at age 40 and screened between 50 and 75 years. S1, 100% screening adherence and 100% colonoscopy follow-up adherence; S2, reported screening adherence and 100% colonoscopy follow-up adherence; S3, reported screening adherence and reported colonoscopy follow-up adherence.
Figure 3.
Figure 3.
Sensitivity analysis. A, Predicted life years-gained (LYG), B, Colorectal cancer incidence and mortality reduction for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) in 3 different adherence scenarios. Results are per 1,000 individuals free of diagnosed colorectal cancer at age 40 and screened between 50 and 75 years. S1, 100% screening adherence and 100% colonoscopy follow-up adherence; S2, sensitivity analysis rates for reported screening adherence and 100% colonoscopy follow-up adherence; S3, sensitivity analysis rates for reported screening adherence and reported colonoscopy follow-up adherence.
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