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. 2000 Apr;46(4):500–506. doi: 10.1136/gut.46.4.500

A decision analysis of surveillance for colorectal cancer in ulcerative colitis

F Delco 1, A Sonnenberg 1
PMCID: PMC1727903  PMID: 10716679

Abstract

BACKGROUND—Patients with long standing, extensive ulcerative colitis have an increased risk of developing colorectal cancer.
AIMS—To assess the feasibility of surveillance colonoscopy in preventing death from colorectal cancer.
PATIENTS—A hypothetical cohort of patients with chronic ulcerative colitis.
METHODS—The benefits of life years saved were weighted against the costs of biannual colonoscopy and proctocolectomy, and the terminal care of patients dying from colorectal cancer. Two separate Markov processes were modelled to compare the cost-benefit relation in patients with or without surveillance. The cumulative probability of developing colorectal cancer served as a threshold to determine which of the two management strategies is associated with a larger net benefit.
RESULTS—If the cumulative probability of colorectal cancer exceeds a threshold value of 27%, surveillance becomes more beneficial than no surveillance. The threshold is only slightly smaller than the actual cumulative cancer rate of 30%. Variations of the assumptions built into the model can raise the threshold above or lower it far below the actual rate. If several of the assumptions are varied jointly, even small changes can lead to extreme threshold values.
CONCLUSIONS—It is not possible to prove that frequent colonoscopies scheduled at regular intervals are an effective means to manage the increased risk of colorectal cancer associated with ulcerative colitis.


Keywords: cancer screening; colorectal cancer; health economics; medical decision analysis; surveillance colonoscopy; ulcerative colitis

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Figure 1  .

Figure 1  

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Markov state diagram of surveillance and no surveillance for colorectal cancer. The white rectangles represent true Markov states where subjects remain for the complete length of a cycle. The shaded rectangles represent intermediate states, which subjects can enter and leave during one cycle before settling in a true Markov state. The transition p represents the incidence rate of cancer per cycle, p' represent the incidence of high grade dysplasia. In patients with high grade dysplasia, dysp represents the fraction of patients with dysplasia alone, while canc represents the fraction of high grade dysplasia accompanied by cancer.

Figure 2  .

Figure 2  

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Cumulative fraction of patients with dysplasia or colorectal cancer (CRC), and surviving fraction of patients remaining free of dysplasia or colorectal cancer. Cumulative fractions were calculated using equations (1) and (3) with %CRC30y = 30%, lag = three years, survival = 100% − cumulative fraction.

Figure 3  .

Figure 3  

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One way sensitivity analyses of the threshold value for cumulative cancer risk. CRC, colorectal cancer.

Figure 4  .

Figure 4  

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Two way sensitivity analysis of the threshold value for cumulative cancer risk. CRC, colorectal cancer.

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These references are in PubMed. This may not be the complete list of references from this article.

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