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Int J Cancer. 2018 Jul 15;143(2):269-282. doi: 10.1002/ijc.31314. Epub 2018 Mar 8.

Evaluation of the benefits, harms and cost-effectiveness of potential alternatives to iFOBT testing for colorectal cancer screening in Australia.

Author information

Cancer Research Division, Cancer Council NSW, New South Wales, Australia.
Prince of Wales Clinical School, University of NSW, New South Wales, Australia.
Prevention Division, Cancer Council Victoria, Melbourne, Victoria, Australia.
Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia.
Department of Colorectal Medicine and Genetics, and Department of Medicine, The Royal Melbourne Hospital and University of Melbourne, Victoria, Australia.
Department of General Practice and Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
Department of Public Health and Primary Care, Primary Care Unit, University of Cambridge, Cambridge, United Kingdom.
Department of Gastroenterology, Sir Charles Gairdner Hospital, Western Australia, Australia.
Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Victoria, Australia.
Cancer Council Australia, Sydney, New South Wales, Australia.
Cancer and Chronic Conditions (C3) Research Group, University of Otago, New Zealand.
Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands.
School of Public Health, Sydney Medical School, University of Sydney, New South Wales, Australia.


The Australian National Bowel Cancer Screening Program (NBCSP) will fully roll-out 2-yearly screening using the immunochemical Faecal Occult Blood Testing (iFOBT) in people aged 50 to 74 years by 2020. In this study, we aimed to estimate the comparative health benefits, harms, and cost-effectiveness of screening with iFOBT, versus other potential alternative or adjunctive technologies. A comprehensive validated microsimulation model, Policy1-Bowel, was used to simulate a total of 13 screening approaches involving use of iFOBT, colonoscopy, sigmoidoscopy, computed tomographic colonography (CTC), faecal DNA (fDNA) and plasma DNA (pDNA), in people aged 50 to 74 years. All strategies were evaluated in three scenarios: (i) perfect adherence, (ii) high (but imperfect) adherence, and (iii) low adherence. When assuming perfect adherence, the most effective strategies involved using iFOBT (annually, or biennially with/without adjunct sigmoidoscopy either at 50, or at 54, 64 and 74 years for individuals with negative iFOBT), or colonoscopy (10-yearly, or once-off at 50 years combined with biennial iFOBT). Colorectal cancer incidence (mortality) reductions for these strategies were 51-67(74-80)% in comparison with no screening; 2-yearly iFOBT screening (i.e. the NBCSP) would be associated with reductions of 51(74)%. Only 2-yearly iFOBT screening was found to be cost-effective in all scenarios in context of an indicative willingness-to-pay threshold of A$50,000/life-year saved (LYS); this strategy was associated with an incremental cost-effectiveness ratio of A$2,984/LYS-A$5,981/LYS (depending on adherence). The fully rolled-out NBCSP is highly cost-effective, and is also one of the most effective approaches for bowel cancer screening in Australia.


Australia; National Bowel Cancer Screening Progam; colonosocopy; colorectal cancer screening; computed tomographic colonography; cost-effectiveness; iFOBT; multitarget faecal DNA testing; plasma DNA testing; sigmoidoscopy

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