年长者进行大肠癌筛检具有成本效益


  【24drs.com】根据6月3日内科医学志发表的研究,未曾进行过大肠直肠癌(CRC)筛检的成年人,进行筛检有其成本效益。
  
  根据作者表示,这是首度探讨未曾进行过筛检之75岁以上长者、进行CRC筛检之健康效益与成本效益的研究。
  
  荷兰鹿特丹Erasmus大学医学中心公卫系Frank van Hees等人写道,这篇研究指出,23%的美国年长者未曾进行过筛检,应考虑对75岁以上者进行CRC筛检;未筛检过、没有其它共病症的年长者中,86岁前要进行CRC筛检(有中度共病症者应在83岁前筛检;有严重共病症者应在80岁前进行),大部份年龄层都适用大肠镜检查。
  
  美国预防服务工作小组建议,50-75岁者进行CRC筛检,但是并未建议已筛检过的75岁以上者再进行筛检,也不清楚那些没有做过CRC筛检者是否要在75岁之后进行。
  
  因此,作者们使用MISCAN-Colon微观仿真模型来模拟生命史,并探讨CRC筛检的健康效益与成本效益。根据观察型和实验型研究的数据,作者们分析了1000万名未筛检过、年龄76-90岁的年长者,共病症状态分为没有、中度与严重。模拟项目包括一次大肠镜检查、乙状结肠镜检查或大便免疫化学测试(FIT)筛检。
  
  研究结果认为,CRC筛检的健康效益随年龄增加而降低。未筛检过、没有其它共病症的年长者中,CRC筛检最多到86岁都还有成本效益,而大肠镜检查适用到最多83岁,乙状结肠镜检查最多适用到84岁,FIT适用到85-86岁。有中度共病症者中,CRC筛检最多到83岁还有成本效益,而大肠镜检查适用到最多80岁,乙状结肠镜检查最多适用到81岁,FIT适用到82-83岁。有严重共病症者中,CRC筛检最多到80岁还有成本效益,而大肠镜检查适用到最多77岁 ,乙状结肠镜检查最多适用到78岁,FIT适用到79-80岁。
  
  模拟项目只包括CRC的平均风险,这可能使结果受限。此外,模拟时并未对性别、种族或高风险族群(例如有CRC家族史者)进行个别分析 。
  
  作者们解释,虽然CRC的发生率随年龄增加,过85岁后到90岁初期,筛检成本效益可能就没有那么高,他们因其它原因而死亡的风险较高,大肠镜检查本身对他们的伤害风险也较大,再者,这个年龄进行筛检可能导致过度治疗,只是多了几年的治疗而不是延长生命。
  
  阿拉巴马大学内科部Amanda V. Clark医师和C. Seth Langefeld医师在编辑评论中强调了这篇研究的两个主要结果,其一,未曾进行过筛检的76岁以上者,CRC盛行率是在50、60和70岁进行过大肠镜检查而结果阴性者的近10倍。其二,那些80岁以上者以及有共病症者,预期寿命迅速减少。
  
  Clark医师表示,这篇研究对于75岁以上、未筛检过的病患有重要意义,并提供了令人信服的证据指出,这些病患可能可以从大肠直肠癌筛检中获益,最好是大肠镜检查、且尽可能在75岁就做。75岁以上且无重大疾病、未曾筛检过者,每人都应考虑进行大肠直肠癌筛检。
  
  虽然这篇研究结果有助于指引年长病患对CRC筛检的决策,但Clark医师强调的是一个以病患为中心的方法。
  
  Clark医师表示,有一个潜在缺点,就是照护者会将这些研究结果视为适用每个病患,她强调,年长者决定进行大肠直肠癌筛检应是个别化的,考量风险与利益,还有个别病患的偏好与价值。
  
  资料来源: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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