Introduction. Recommendations for colorectal cancer screening encourage patients to choose among various screening methods based on individual preferences for benefits, risks, screening frequency, and discomfort. We devised a model to illustrate how individuals with varying tolerance for screening complications risk might decide on their preferred screening strategy. Methods. We developed a discrete-time Markov mathematical model that allowed hypothetical individuals to maximize expected lifetime utility by selecting screening method, start age, stop age, and frequency. Individuals could choose from stool-based testing every 1 to 3 years, flexible sigmoidoscopy every 1 to 20 years with annual stool-based testing, colonoscopy every 1 to 20 years, or no screening. We compared the life expectancy gained from the chosen strategy with the life expectancy available from a benchmark strategy of decennial colonoscopy. Results. For an individual at average risk of colorectal cancer who was risk neutral with respect to screening complications (and therefore was willing to undergo screening if it would actuarially increase life expectancy), the model predicted that he or she would choose colonoscopy every 10 years, from age 53 to 73 years, consistent with national guidelines. For a similar individual who was moderately averse to screening complications risk (and therefore required a greater increase in life expectancy to accept potential risks of colonoscopy), the model predicted that he or she would prefer flexible sigmoidoscopy every 12 years with annual stool-based testing, with 93% of the life expectancy benefit of decennial colonoscopy. For an individual with higher risk aversion, the model predicted that he or she would prefer 2 lifetime flexible sigmoidoscopies, 20 years apart, with 70% of the life expectancy benefit of decennial colonoscopy. Conclusion. Mathematical models may formalize how individuals with different risk attitudes choose between various guideline-recommended colorectal cancer screening strategies.
US Preventive Services Task Force, Bibbins-DomingoKGrossmanDC. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(23):2564–75.
2.
KnudsenABZauberAGRutterCM. Estimation of benefits, burden, and harms of colorectal cancer screening strategies: modeling study for the US Preventive Services Task Force. JAMA. 2016;315(23):2595–609.
3.
AkerkarGAYeeJHungRMcQuaidK.Patient experience and preferences toward colon cancer screening: a comparison of virtual colonoscopy and conventional colonoscopy. Gastrointest Endosc. 2001;54(3):310–5.
4.
HawleySTVolkRJKrishnamurthyPJibaja-WeissMVernonSWKneuperS.Preferences for colorectal cancer screening among racially/ethnically diverse primary care patients. Med Care. 2008;46(9, Suppl 1):S10–6.
5.
KatzMLJamesASPignoneMP. Colorectal cancer screening among African American church members: a qualitative and quantitative study of patient-provider communication. BMC Public Health. 2004;4:62.
6.
AriasE.United States Life Tables, 2011. Natl Vital Stat Rep. 2015;64(11):1–63.
7.
BrennerHChang-ClaudeJSeilerCMRickertAHoffmeisterM.Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med. 2011;154(1):22–30.
8.
ShapiroJAKlabundeCNThompsonTDNadelMRSeeffLCWhiteA.Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev. 2012;21(6):895–904.
9.
Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: incidence—SEER 18 Regs research data + Hurricane Katrina impacted Louisiana cases, Nov 2013 Sub (1973–2011 varying)—linked to county attributes—total U.S., 1969–2012 counties, National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2014 (updated 5/7/2014), based on the November 2013 submission. Available from:www.seer.cancer.gov
10.
Centers for Medicare & Medicaid Services. Medicare & You:2016. CMS Product 10050. US Department of Health and Human Services. Available from:http://www.medicare.gov/Pubs/pdf/10050.pdf
11.
WarrenJLKlabundeCNMariottoAB. Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med. 2009;150(12):849–57, W152.
12.
LaibsonDRepettoATobacmanmJ.Estimating discount functions with consumption choices over the lifecycle. NBER Working Paper 13314. August2007. Cambridge, MA: National Bureau of Economic Research.
13.
GourinchasPParkerJ.Consumption over the life cycle. Econometrica. 2002;70(1):47–89.
14.
MankiwNZeldesS.The consumption of stockholders and non-stockholders. J Financial Econ. 1991;29(1):97–112.
15.
ParrinoRPoteshmanAWeisbachM. Measuring investment distortions when risk-averse managers decide whether to undertake risky projects. NBER Working Paper 8763. February2002. Cambridge, MA: National Bureau of Economic Research.
16.
PindyckR.Risk aversion and determinants of stock market behavior. Rev Econ Stat. 1998;52(2):183–90.
17.
GuisoLSapienzaPZingalesL.Time varying risk aversion. NBER Working Paper 19284. August2013. Cambridge, MA: National Bureau of Economic Research.
18.
EinavLFinkelsteinAPascuICullenM.How general are risk preferences? Choices under uncertainty in different domains. Am Econ Rev. 2012;102(6):2606–38.
19.
LinJSPiperMAPerdueLA. Screening for colorectal cancer: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;315(23):2576–94.
20.
ElmunzerBJHaywardRASchoenfeldPSSainiSDDeshpandeAWaljeeAK.Effect of flexible sigmoidoscopy-based screening on incidence and mortality of colorectal cancer: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2012;9(12):e1001352.
21.
LittlejohnCHiltonSMacfarlaneGJPhullP.Systematic review and meta-analysis of the evidence for flexible sigmoidoscopy as a screening method for the prevention of colorectal cancer. Br J Surg. 2012;99(11):1488–500.
22.
BraithwaiteRS.Can life expectancy and QALYs be improved by a framework for deciding whether to apply clinical guidelines to patients with severe comorbid disease?Med Decis Making. 2011;31(4):582–95.
23.
RansohoffDF.How much does colonoscopy reduce colon cancer mortality?Ann Intern Med. 2009;150(1):50–2.
24.
BaxterNNGoldwasserMAPaszatLFSaskinRUrbachDRRabeneckL.Association of colonoscopy and death from colorectal cancer. Ann Intern Med. 2009;150(1):1–8.
25.
HewitsonPGlasziouPWatsonETowlerBIrwigL.Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (Hemoccult): an update. Am J Gastroenterol. 2008;103(6):1541–9.
26.
HewitsonPGlasziouPIrwigLTowlerBWatsonE.Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev. 2007;(1):CD001216.
27.
KoCWSonnenbergA.Comparing risks and benefits of colorectal cancer screening in elderly patients. Gastroenterology. 2005;129(4):1163–70.
28.
NessRMHolmesAMKleinRDittusR.Utility valuations for outcome states of colorectal cancer. Am J Gastroenterol. 1999;94(6):1650–7.
29.
ZauberAGLansdorp-VogelaarIKnudsenABWilschutJvan BallegooijenMKuntzKM.Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(9):659–69.
30.
AndersonLRMellorJM.Predicting health behaviors with an experimental measure of risk preference. J Health Econ. 2008;27(5):1260–74.
31.
LevinBLiebermanDAMcFarlandB; American Cancer Society Colorectal Cancer Advisory Group, US Multi-Society Task Force, American College of Radiology Colon Cancer Committee. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008;134(5):1570–95.
32.
WeinbergDSSchoenRE.In the clinic: screening for colorectal cancer. Ann Intern Med. 2014;160(9).
33.
JohnsLEHoulstonRS.A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol. 2001;96(10):2992–3003.
34.
EnestvedtBKEisenGMHolubJLiebermanDA.Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?Gastrointest Endosc. 2013;77(3):464–71.
35.
Lansdorp-VogelaarIvan BallegooijenMZauberAG. Individualizing colonoscopy screening by sex and race. Gastrointest Endosc. 2009;70(1):96–108.e1–24.
36.
WilschutJASteyerbergEWvan LeerdamMELansdorp-VogelaarIHabbemaJDvan BallegooijenM.How much colonoscopy screening should be recommended to individuals with various degrees of family history of colorectal cancer?Cancer. 2011;117(18):4166–74.
37.
van HeesFSainiSDLansdorp-VogelaarI. Personalizing colonoscopy screening for elderly individuals based on screening history, cancer risk, and comorbidity status could increase cost effectiveness. Gastroenterology. 2015;149(6):1425–37.
38.
SainiSDvan HeesFVijanS.Smarter screening for cancer: possibilities and challenges of personalization. JAMA. 2014;312(21):2211–2.
39.
TakslerGBKeshnerMFagerlinAHajizadehNBraithwaiteRS.Personalized estimates of benefit from preventive care guidelines: a proof of concept. Ann Intern Med. 2013;159(3):161–8.
40.
JeonJBerndtSIBrennerH. Comprehensive colorectal cancer risk prediction to inform personalized screening and intervention. Paper presented at the American Association for Cancer Research;18April2016; New Orleans, LA.
41.
SussmanJBVijanSChoiHHaywardRA.Individual and population benefits of daily aspirin therapy: a proposal for personalizing national guidelines. Circ Cardiovasc Qual Outcomes. 2011;4(3):268–75.
42.
VijanSSussmanJBYudkinJSHaywardRA.Effect of patients’ risks and preferences on health gains with plasma glucose level lowering in type 2 diabetes mellitus. JAMA Intern Med. 2014;174(8):1227–34.
43.
ZulmanDMVijanSOmennGSHaywardRA.The relative merits of population-based and targeted prevention strategies. Milbank Q. 2008;86(4):557–80.
44.
Centers for Disease Control and Prevention. National Health Interview Survey: questionnaires, datasets, and related documentation. Available from: http://www.cdc.gov/nchs/nhis.htm
BeekerCKraftJMSouthwellBGJorgensenCM.Colorectal cancer screening in older men and women: qualitative research findings and implications for intervention. J Community Health. 2000;25(3):263–78.
47.
BrettAS.Flexible sigmoidoscopy for colorectal cancer screening: more evidence, persistent ironies. JAMA. 2014;312(6):601–2.
48.
ChoHKlabundeCNYabroffKR. Comorbidity-adjusted life expectancy: a new tool to inform recommendations for optimal screening strategies. Ann Intern Med. 2013;159(10):667–76.
