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The predicted impact and cost-effectiveness of systematic testing of people with incident colorectal cancer for Lynch syndrome

Kang, Yoon-Jung, Killen, James, Caruana, Michael, Simms, Kate, Taylor, Natalie, Frayling, Ian M., Snowsill, Tristan, Huxley, Nicola, Coupe, Veerle MH, Hughes, Suzanne, Freeman, Victoria, Boussioutas, Alex, Trainer, Alison H, Ward, Robyn L, Mitchell, Gillian, Macrae, Finlay A and Canfell, Karen 2020. The predicted impact and cost-effectiveness of systematic testing of people with incident colorectal cancer for Lynch syndrome. Medical Journal of Australia 212 (2) , pp. 72-81. 10.5694/mja2.50356

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OBJECTIVES: To evaluate the health impact and cost-effectiveness of systematic testing for Lynch syndrome (LS) in people with incident colorectal cancer (CRC) in Australia. DESIGN, SETTING, PARTICIPANTS: We investigated the impact of LS testing strategies in a micro-simulation model (Policy1-Lynch), explicitly modelling the cost of testing all patients diagnosed with incident CRC during 2017, with detailed modelling of outcomes for patients identified as LS carriers (probands) and their at-risk relatives throughout their lifetimes. For people with confirmed LS, we modelled ongoing colonoscopic surveillance. MAIN OUTCOME MEASURES: Cost-effectiveness of six universal tumour testing strategies (testing for DNA mismatch repair deficiencies) and of universal germline gene panel testing of patients with incident CRC; impact on cost-effectiveness of restricting testing by age at CRC diagnosis (all ages, under 50/60/70 years) and of colonoscopic surveillance interval (one, two years). RESULTS: The cost-effectiveness ratio of universal tumour testing strategies (annual colonoscopic surveillance, no testing age limit) compared with no testing ranged from $28 915 to $31 904/life-year saved (LYS) (indicative willingness-to-pay threshold: $30 000-$50 000/LYS). These strategies could avert 184-189 CRC deaths with an additional 30 597-31 084 colonoscopies over the lifetimes of 1000 patients with incident CRC with LS and 1420 confirmed LS carrier relatives (164-166 additional colonoscopies/death averted). The most cost-effective strategy was immunohistochemistry and BRAF V600E testing (incremental cost-effectiveness ratio [ICER], $28 915/LYS). Universal germline gene panel testing was not cost-effective compared with universal tumour testing strategies (ICER, $2.4 million/LYS). Immunohistochemistry and BRAF V600E testing was cost-effective at all age limits when paired with 2-yearly colonoscopic surveillance (ICER, $11 525-$32 153/LYS), and required 4778-15 860 additional colonoscopies to avert 46-181 CRC deaths (88-103 additional colonoscopies/death averted). CONCLUSIONS: Universal tumour testing strategies for guiding germline genetic testing of people with incident CRC for LS in Australia are likely to be cost-effective compared with no testing. Universal germline gene panel testing would not currently be cost-effective.

Item Type: Article
Date Type: Publication
Status: Published
Schools: Medicine
Publisher: Australasian Medical Publishing Company Ltd
ISSN: 0025-729X
Date of First Compliant Deposit: 8 November 2019
Date of Acceptance: 1 June 2019
Last Modified: 18 Feb 2020 12:20

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