Artificial Intelligence Can Cut Costs While Maintaining Accuracy in Colorectal Cancer Genotyping

Abstract

Rising cancer care costs impose financial burdens on health systems. Applying artificial intelligence to diagnostic algorithms may reduce testing costs and avoid wasteful therapy-related expenditures. To evaluate the financial and clinical impact of incorporating artificial intelligence-based determination of mismatch repair/microsatellite instability status into the first-line metastatic colorectal carcinoma setting, we developed a deterministic model to compare eight testing strategies: A) next-generation sequencing alone, B) high-sensitivity polymerase chain reaction or immunohistochemistry panel alone, C) high-specificity panel alone, D) high-specificity artificial intelligence alone, E) high-sensitivity artificial intelligence followed by next generation sequencing, F) high-specificity artificial intelligence followed by next-generation sequencing, G) high-sensitivity artificial intelligence and high-sensitivity panel, and H) high-sensitivity artificial intelligence and high-specificity panel. We used a hypothetical, nationally representative, population-based sample of individuals receiving first-line treatment for de novo metastatic colorectal cancer (N = 32,549) in the United States. Model inputs were derived from secondary research (peer-reviewed literature and Medicare data). We estimated the population-level diagnostic costs and clinical implications for each testing strategy. The testing strategy that resulted in the greatest project cost savings (including testing and first-line drug cost) compared to next-generation sequencing alone in newly-diagnosed metastatic colorectal cancer was using high-sensitivity artificial intelligence followed by confirmatory high-specificity polymerase chain reaction or immunohistochemistry panel for patients testing negative by artificial intelligence ($400 million, 12.9%). The high-specificity artificial intelligence-only strategy resulted in the most favorable clinical impact, with 97% diagnostic accuracy in guiding genotype-directed treatment and average time to treatment initiation of less than one day. Artificial intelligence has the potential to reduce both time to treatment initiation and costs in the metastatic colorectal cancer setting without meaningfully sacrificing diagnostic accuracy. We expect the artificial intelligence value proposition to improve in coming years, with increasing diagnostic accuracy and decreasing costs of processing power. To extract maximal value from the technology, health systems should evaluate integrating diagnostic histopathologic artificial intelligence into institutional protocols, perhaps in place of other genotyping methodologies.

Keywords: artificial intelligence; colorectal (colon) cancer; cost savings; deep learning; digital biomarker; digital pathology; financial implication; microsatellite instability (MSI).

Figure 1

Treatment decision tree with various testing strategies. (A) Next-generation sequencing alone; (B) High-sensitivity immunohistochemistry panel alone; (C) High-specificity immunohistochemistry panel alone; (D) High-specificity artificial intelligence alone; (E) High-sensitivity artificial intelligence followed by next-generation sequencing for individuals with deficient mismatch repair/microsatellite instability-high tumors by artificial intelligence; (F) High-specificity artificial intelligence followed by next-generation sequencing for individuals with intact mismatch repair/microsatellite stable tumors by artificial intelligence; (G) High-sensitivity artificial intelligence followed by high-sensitivity immunohistochemistry panel for individuals with deficient mismatch repair/microsatellite instability-high tumors by artificial intelligence; (H) High-sensitivity artificial intelligence followed by high-specificity immunohistochemistry panel for individuals with deficient mismatch repair/microsatellite instability-high tumors by artificial intelligence. AI, artificial intelligence; CTx, chemotherapy; dMMR, deficient mismatch repair; FU, fluorouracil; IHC, immunohistochemistry; mCRC, metastatic colorectal cancer; MSI-H, microsatellite instability-high; MSS, microsatellite-stable; NGS, next-generation sequencing; PCR, polymerase chain reaction; PFS, progression-free survival; pMMR, proficient mismatch repair.

Figure 2

Comparison of total testing and treatment-related costs by clinical scenario. AI, artificial intelligence; IHC, immunohistochemistry; NGS, next-generation sequencing; PCR, polymerase chain reaction.