1. Colorectal Cancer Screening - Economic Considerations Terri Green University of Canterbury Presentation for “Future of Cancer Screening in New Zealand”. Auckland, 7 August 2015

2. Economic considerations Is it value for money? (Yes, potentially) –What are the benefits? –What are the costs? Can we achieve the benefits? Can we afford it? Are there alternatives? 2

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4. Fig 3. Biennial FOBTi screening, 50-74 years: Referral and Surveillance colonoscopy 2011-2031 (Participation 60%, Positivity 6.4%, 4.8%) Green, Richardson and Parry (NZMJ, 2012) 4

5. Can we do it? 18000 colonoscopies rising to 28000 Assumes –Participation 60% Compared to 55% for pilot –Positivity 6.4% for initial screen –4.8% for later screens Compared to 7.5% for pilot 5

6. What is the cost of Programme? - estimated at $39 M per year* (Sapere, 2015) (Steady state cost; initial years more costly) Key Determinants of cost: Participation rate in screening (pilot, 55%) Positivity rate (pilot, 7.5%) How programme is delivered: –Use of private sector for colonoscopies –Regional variations (*Range $26M-$50M, Sapere report MOH 2015) 6

7. Can we afford “it”? Depends on other demands on public money …… (Annual CRC treatment costs approx $83M*.) If it can be delivered it is worthy of consideration Are there alternatives to address Bowel cancer? E.G. screening by once only Flexible Sigmoidoscopy. (*Sheerin, Green, Sarfati, Cox, NZMJ 2015) 7

8. Approx Comparison: Annual volumes FOBTi and Flexible Sigmoidoscopy (60% participation) FOBTi (50-74, every 2 years) 618,000 target 371,000 screens 18,000 colonoscopies Flex sig (one-off, age 55) 60,000 target 36,000 screens 1800* colonoscopies (* 5%, Atkins, Lancet, 2010) 8

9. Balancing costs and benefits: - FOBTi, compared to Flex sig Greater Reduction in CRC incidence√ Greater Reduction in mortality √ Higher cost Lower cost per QALY √ More adverse events Higher colonoscopy load 9