• Meester Reinier G S RGS Erasmus MC University Medical Center, Rotterdam, the Netherlands, and Stanford University, Stanford, California (R.G.M.)., Iris Lansdorp-Vogelaar, Sidney J Winawer, Ann G Zauber, Amy B Knudsen, and Uri Ladabaum.
• Erasmus MC University Medical Center, Rotterdam, the Netherlands, and Stanford University, Stanford, California (R.G.M.).
• Ann. Intern. Med. 2019 Nov 5; 171 (9): 612-622.

BackgroundSurveillance of patients with colorectal adenomas has limited long-term evidence to support current practice.ObjectiveTo compare the lifetime benefits and costs of high- versus low-intensity surveillance.DesignMicrosimulation model.Data SourcesU.S. cancer registry, cost data, and published literature.Target PopulationU.S. patients aged 50, 60, or 70 years with low-risk adenomas (LRAs) (1 to 2 small adenomas) or high-risk adenomas (HRAs) (3 to 10 small adenomas or ≥1 large adenoma) removed after screening with colonoscopy or fecal immunochemical testing (FIT).Time HorizonLifetime.PerspectiveSocietal.InterventionNo further screening or surveillance, routine screening after 10 years, low-intensity surveillance (10 years after LRA removal and 5 years after HRA removal), and high-intensity surveillance (5 years after LRA removal and 3 years after HRA removal).Outcome MeasuresColorectal cancer (CRC) incidence and incremental cost-effectiveness.Results Of Base Case AnalysisWithout surveillance or screening, lifetime CRC incidence for patients aged 50 years was 10.9% after LRA removal and 17.2% after HRA removal at screening colonoscopy. Subsequent colonoscopic screening, low-intensity surveillance, or high-intensity surveillance decreased incidence by 39%, 46% to 48%, and 55% to 56%, respectively. Incidence of CRC and surveillance benefits were higher for adenomas detected at FIT screening and lower for older patients. High-intensity surveillance cost less than $30 000 per quality-adjusted life-year (QALY) gained compared with low-intensity surveillance.Results Of Sensitivity AnalysisHigh-intensity surveillance cost less than $100 000 per QALY gained in most alternative scenarios for adenoma recurrence, CRC incidence, longevity, quality of life, screening ages, surveillance ages, test performance, disutilities, and cost.LimitationFew surveillance outcome data exist.ConclusionThe model suggests that high-intensity surveillance as recommended in the United States provides modest but clinically relevant benefits over low-intensity surveillance at acceptable cost.Primary Funding SourceNational Cancer Institute.

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