年長者進行大腸癌篩檢具有成本效益


  【24drs.com】根據6月3日內科醫學誌發表的研究,未曾進行過大腸直腸癌(CRC)篩檢的成年人,進行篩檢有其成本效益。
  
  根據作者表示,這是首度探討未曾進行過篩檢之75歲以上長者、進行CRC篩檢之健康效益與成本效益的研究。
  
  荷蘭鹿特丹Erasmus大學醫學中心公衛系Frank van Hees等人寫道,這篇研究指出,23%的美國年長者未曾進行過篩檢,應考慮對75歲以上者進行CRC篩檢;未篩檢過、沒有其他共病症的年長者中,86歲前要進行CRC篩檢(有中度共病症者應在83歲前篩檢;有嚴重共病症者應在80歲前進行),大部份年齡層都適用大腸鏡檢查。
  
  美國預防服務工作小組建議,50-75歲者進行CRC篩檢,但是並未建議已篩檢過的75歲以上者再進行篩檢,也不清楚那些沒有做過CRC篩檢者是否要在75歲之後進行。
  
  因此,作者們使用MISCAN-Colon微觀仿真模型來模擬生命史,並探討CRC篩檢的健康效益與成本效益。根據觀察型和實驗型研究的數據,作者們分析了1000萬名未篩檢過、年齡76-90歲的年長者,共病症狀態分為沒有、中度與嚴重。模擬項目包括一次大腸鏡檢查、乙狀結腸鏡檢查或大便免疫化學測試(FIT)篩檢。
  
  研究結果認為,CRC篩檢的健康效益隨年齡增加而降低。未篩檢過、沒有其他共病症的年長者中,CRC篩檢最多到86歲都還有成本效益,而大腸鏡檢查適用到最多83歲,乙狀結腸鏡檢查最多適用到84歲,FIT適用到85-86歲。有中度共病症者中,CRC篩檢最多到83歲還有成本效益,而大腸鏡檢查適用到最多80歲,乙狀結腸鏡檢查最多適用到81歲,FIT適用到82-83歲。有嚴重共病症者中,CRC篩檢最多到80歲還有成本效益,而大腸鏡檢查適用到最多77歲 ,乙狀結腸鏡檢查最多適用到78歲,FIT適用到79-80歲。
  
  模擬項目只包括CRC的平均風險,這可能使結果受限。此外,模擬時並未對性別、種族或高風險族群(例如有CRC家族史者)進行個別分析 。
  
  作者們解釋,雖然CRC的發生率隨年齡增加,過85歲後到90歲初期,篩檢成本效益可能就沒有那麼高,他們因其他原因而死亡的風險較高,大腸鏡檢查本身對他們的傷害風險也較大,再者,這個年齡進行篩檢可能導致過度治療,只是多了幾年的治療而不是延長生命。
  
  阿拉巴馬大學內科部Amanda V. Clark醫師和C. Seth Langefeld醫師在編輯評論中強調了這篇研究的兩個主要結果,其一,未曾進行過篩檢的76歲以上者,CRC盛行率是在50、60和70歲進行過大腸鏡檢查而結果陰性者的近10倍。其二,那些80歲以上者以及有共病症者,預期壽命迅速減少。
  
  Clark醫師表示,這篇研究對於75歲以上、未篩檢過的病患有重要意義,並提供了令人信服的證據指出,這些病患可能可以從大腸直腸癌篩檢中獲益,最好是大腸鏡檢查、且盡可能在75歲就做。75歲以上且無重大疾病、未曾篩檢過者,每人都應考慮進行大腸直腸癌篩檢。
  
  雖然這篇研究結果有助於指引年長病患對CRC篩檢的決策,但Clark醫師強調的是一個以病患為中心的方法。
  
  Clark醫師表示,有一個潛在缺點,就是照護者會將這些研究結果視為適用每個病患,她強調,年長者決定進行大腸直腸癌篩檢應是個別化的,考量風險與利益,還有個別病患的偏好與價值。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=7085&x_classno=0&x_chkdelpoint=Y
  

Colon Cancer Screening Cost-Effective in Older Adults

By Veronica Hackethal, MD
Medscape Medical News

Colorectal cancer (CRC) screening is cost-effective in adults older than 75 years who have not had prior screening, according to a study published in the June 3 issue of the Annals of Internal Medicine.

The study is the first, according to the authors, to look at the health benefits and cost-effectiveness of CRC screening in people older than 75 years without prior screening.

"[O]ur study demonstrates that in the 23% of U.S. elderly persons without previous screening, CRC screening should be considered well beyond age 75 years," write Frank van Hees, MSc, from the Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues. "In unscreened elderly persons with no comorbid conditions, CRC screening should be considered up to age 86 years (up to age 83 years for those with moderate comorbid conditions and up to age 80 years for those with severe comorbid conditions). Screening with colonoscopy is indicated at most ages."

The US Preventative Services Task Force recommends screening for CRC from ages 50 to 75 years but does not recommend it for those older than 75 years who have already been screened. However, it remains unclear whether or not those without prior CRC screening should receive it after age 75 years.

Therefore, the authors used the MISCAN-Colon microsimulation model to simulate life histories and look at the health benefits and cost-effectiveness of CRC screening. Using data from observational and experimental studies, the authors constructed a cohort of 10 million previously unscreened people between the ages of 76 and 90 years, with comorbidities categorized as none, moderate, and severe. Simulations included 1-time colonoscopy, sigmoidoscopy, or fecal immunochemical test (FIT) screening.

The results suggest that the health benefits of CRC screening decreased with advanced age. Among unscreened elderly patients without comorbidities, CRC screening remained cost-effective up to age 86 years, with colonoscopy indicated up to age 83 years, sigmoidoscopy at age 84 years, and FIT at ages 85 and 86 years. Among those with moderate comorbidities, screening remained cost-effective up to age 83 years, with colonoscopy indicated up to age 80 years, sigmoidoscopy at age 81 years, and FIT at ages 82 and 83 years. Among those with severe comorbidities, screening was cost-effective up to age 80 years, with colonoscopy indicated up to age 77 years, sigmoidoscopy at age 78 years, and FIT at 79 and 80 years.

Simulations only included those at average risk for CRC, which could have limited the results. In addition, simulations did not include separate analyses for sex, race, or high-risk groups, such as those patients with a family history of CRC.

The authors explain that although the incidence of CRC increases with advancing age, screening likely does not remain cost-effective among elderly patients in their late 80s and early 90s because of their higher risk for death from other causes, as well as the risk for harm caused by colonoscopy itself. Moreover, screening at these ages could cause overtreatment, which may only add more years of medical treatment rather than prolonging life.

In an accompanying editorial, Amanda V. Clark, MD, and C. Seth Langefeld, MD, both from the Department of Internal Medicine at the University of Alabama at Birmingham, highlighted 2 main results of the study. First, those aged 76 years and older without prior screening had a prevalence of CRC that was nearly 10 times greater than in those who had negative results on screening colonoscopy at ages 50, 60, and 70 years. Second, life expectancy decreased rapidly in those older than 80 years and among those with comorbidities.

"This study has important implications regarding unscreened patients over age 75 and provides compelling evidence that these patients would likely benefit from colorectal cancer screening, preferably colonoscopy, and as close to age 75 as possible," Dr. Clark told Medscape Medical News. "Colorectal cancer screening should be considered in every person over age 75 without fatal illness who has not had prior screening."

Although mentioning that results from this study could help guide CRC screening decisions among elderly patients, Dr. Clark emphasized a patient-centered approach.

"One potential drawback is that [providers] will view these findings as recommendations that can be generalized to every patient," Dr. Clark emphasized, "The decision for an older person to undergo colorectal cancer screening should be individualized, contemplating both risks and benefits in addition to the patient's preferences and values."

All but 1 of the authors has reported receiving grants from the National Cancer Institute during the conduct of the study. The remaining author and the editorialists have disclosed no relevant financial relationships.

Ann Intern Med. 2014;160:750-759, 804-805.

    
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