Catherine Lejeune

Use of a decision analysis model to assess the medicoeconomic implications of FDG PET imaging in diagnosing a solitary pulmonary nodule.

This study assessed the use of positron emission tomography (PET) in identifying and diagnosing solitary pulmonary nodules (SPNs). For this a decision analysis model was constructed, and three alternatives were compared: wait and watch (WW), PET and anatomical computed tomography (PET), and CT plus PET (CT+PET). Transition probabilities were estimated from published data and consultations with experts. Costs of diagnosis were derived from the French reimbursement scale, and treatment costs from a national hospital database of diagnosis-related groups. The base case was defined as a 65-year-old male smoker with a 2-cm SPN and an associated high risk of malignancy of 43%. Evaluation criteria included incremental cost-effectiveness ratios and the proportion of unnecessary operations avoided in patients without malignant SPN. For the base case WW was the least effective and cheapest strategy. CT+PET was more effective and presented lower incremental cost-effectiveness ratio (€3,022 per life-year gained). It also was superior to PET in cost-effectiveness terms and resulted in 4.3% fewer unnecessary resections of benign SPN than did PET. Risk profile analyses performed on SPN malignancy risk showed that CT + PET remains the most cost-effective strategy in the range of 5.7–87%, and that WW is more cost-effective in the range of 0.3–5.0%. CT+PET is thus cost-effective in detecting malignant SPN in patients with a risk of malignity of at least 5.7% and may avoid inappropriate resections of benign SPN. These findings support the attempts to introduce a larger number of PETs in France for SPN diagnosis.

Cost-effectiveness analysis of fecal occult blood screening for colorectal cancer.

OBJECTIVES Clinical trials have demonstrated that fecal occult blood screening for colorectal cancer can significantly reduce mortality. However, to be deemed a priority from a public health policy perspective, any new program must prove itself to be cost-effective. The objective of this study was to assess the cost-effectiveness of screening for colorectal cancer using a fecal occult blood screening test, the Hemoccult-II, in a cohort of 100,000 asymptomatic individuals 50-74 years of age. METHODS A decision analysis model using a Markov approach simulates the trajectory of the cohort allocated either to screening or no screening over a 20-year period through several health states. Clinical and economic data used in the model came from the Burgundy trial, French population-based studies, and Registry data. RESULTS Modeling biennial screening versus the absence of screening over a 20-year period resulted in a 17.7 percent mortality reduction and a discounted incremental cost-effectiveness ratio of 3357 Euro per life-year gained among individuals 50-74 years of age. Sensitivity analyses performed on epidemiological and economic data showed the strong impact on the results of colonoscopy cost, of compliance to screening, and of specificity of the screening test. CONCLUSIONS Cost-effectiveness estimates and sensitivity analyses suggest that biennial screening for colorectal cancer with fecal occult blood test could be recommended from the age of 50 until 74. Our findings support the attempts to introduce large-scale population screening programs.

Patterns of Surveillance Practices After Curative Surgery for Colorectal Cancer in a French Population

PURPOSEDespite controversies, postoperative surveillance of colorectal cancer is generally recommended. This registry-based study was designed to assess the adherence of surveillance practices to French guidelines and identify three-year surveillance patterns and their demographic and clinical determinants.METHODSAll patients (N = 409) diagnosed with first colorectal cancer in 1998 and alive without recurrence at least six months after curative surgery were identified from a population-based registry. Medical charts from multiple sources were reviewed to collect exhaustive information on follow-up procedures used during a three-year period. Multiple correspondence and cluster analyses were used to identify surveillance patterns.RESULTSThe proportion of patients with a lower surveillance than that recommended was 35 percent for clinical examination, 65 percent for abdominal ultrasound, 52 percent for chest x-ray, and 20 percent for colonoscopy. Cluster analysis identified three patterns called minimal, moderate, and intensive surveillance patterns, which included 47, 24, and 29 percent of the patients respectively. The main independent predictors of both moderate and intensive surveillance patterns vs. minimal pattern were advanced tumor stage, chemotherapy, and radiation therapy. Younger age also was strongly associated with the intensive surveillance pattern, and the presence of symptoms with the moderate surveillance pattern.CONCLUSIONSAdherence of surveillance practices to French guidelines seems relatively poor. Surveillance patterns are mainly explained by patient age, tumor stage, and treatment modalities.

Which patients with colorectal cancer are followed up by general practitioners? A population-based study.

The aim of the study was to assess the contribution of general practitioners in the surveillance of colorectal cancer, and to examine characteristics and survival of patients with routine general practitioner follow-up. This French registry-based study included 389 patients diagnosed with first colorectal cancer in 1998 and free of disease at least 6 months after curative surgery. For each physician involved, medical records were thoroughly reviewed to collect information about the clinical examinations and follow-up tests prescribed within 3 years after surgery or until death or detection of recurrence. Five-year vital status was obtained through registry records. The proportion of routine clinical examinations performed by general practitioners increased from 35% in the first year to 65% in the third year. Patients having undergone regular general practitioner routine examinations (≥one examination every 6-month period) had significantly less advanced disease (odds ratio: 0.45; 95% confidence interval: 0.21–0.96), preoperative complications (odds ratio: 0.28; 95% confidence interval: 0.08–0.91) and routine examinations by gastroenterologists/oncologists (odds ratio: 0.37; 95% confidence interval: 0.14–0.98) compared with those without general practitioner examinations. Routine general practitioner follow-up had no influence on 3 and 5-year survival. General practitioners detected significantly more recurrences than specialists in patients over 75 and in those presenting symptoms. French general practitioners are widely involved in the surveillance of patients with early-stage colorectal cancer, without any unfavourable impact on the patients survival. Some suggestions exist that continuing education in oncology may increase the implication of general practitioners in colorectal cancer surveillance.

Family history and risk of colorectal cancer: implications for screening programmes

Objective To estimate the lifetime risk of colorectal cancer in the general population and in first degree relatives of patients with sporadic colorectal cancer or adenoma. Main outcomes measures The cumulative risk of colorectal cancer (0–74) in the general population combined with the relative risk of colorectal cancer and the prevalence of different groups of subjects with family history of colorectal tumour allows the calculation of cumulative risks in these groups. Results The lifetime risk of colorectal cancer was 1 in 23 in men and 1 in 40 in women. In males, 0.5% in the 55–59 age group and 4.5% in the 70–74 age group will develop a colorectal cancer. The corresponding values in females were 0.4% and 2.5%. The cumulative risk at age 74 varied between 7.7% (one family member affected) and 25.6% (two affected) in males, and 4.3% and 14.3% respectively in females. The risk in the 40–44 year age group for individuals with one first degree relative affected before 45 years of age was 0.5%, similar to that of those aged 45–49 with one first degree relative affected with a colorectal cancer or a large adenoma (> 1 cm). Conclusions These results suggest that screening in the general population should start at 50 or 55. The lifetime risk is high enough (over 10%) among individuals with one affected first degree relative before age 45, or with at least two affected first degree relatives, to warrant colonoscopic screening. The data provide a basis for recommendations that relatives of these patients should enter screening programmes at age 40 to 44.

Interval cancers in a community-based programme of colorectal cancer screening with faecal occult blood test.

Interval cancers represent the major limitation of screening for colorectal cancer with the faecal occult blood test. The aim of this study was to describe the characteristics of interval cancers and the sensitivity of the screening programme in a well-defined French population. During five screening rounds, 398 cancers were diagnosed in those of the population having performed at least one screening test; 57.8% of them were interval cancers. The proportion of interval cancers was higher among cancers of the rectal ampulla (72.2%) than among cancers of other sites (52.9%) (P < 0.001). The proportion of TNM stage I and II were higher among screen-detected cancers (73.8%) than among interval cancers (57.4%). The overall sensitivity of the screening programme was 62.9% within 1 year, and 48.7% within 2 years. An improvement in the sensitivity of the faecal occult blood test for colorectal cancer screening is needed, without an unacceptable loss of specificity.

The cost-effectiveness of immunochemical tests for colorectal cancer screening

BACKGROUND The optimal immunochemical test to use for generalised mass screening is still under debate in France. AIM To compare the cost and effectiveness in biennial screening for colorectal cancer of fifteen strategies consisting of the three-stool sample un-rehydrated guaiac faecal occult blood test and three immunochemical tests: Magstream, FOB-Gold and OC-Sensor, at different positivity cut-off levels and stool-sample collection. METHODS A Markov model was used to compare these strategies in a general population of 100,000 individuals aged 50-74 over a 20-year period. RESULTS Immunochemical tests were efficient strategies compared with guaiac faecal occult blood test. When all 15 strategies were compared with each other, only five of them remained efficient: the one- and two-stool sample Magstream, the one- and two-stool sample FOB-Gold with the 176 ng/mL cut-off, and the two-stool sample OC-Sensor with the 150 ng/mL cut-off. Sensitivity analyses showed that, at an identical price, the one-stool sample OC-Sensor was the most efficient strategy, and outperformed FOB-Gold. CONCLUSION One-stool immunochemical testing can be considered a promising alternative to the guaiac faecal occult blood test for colorectal cancer mass screening in the general population. Competition between manufacturers should now be introduced to reduce purchase price differences.

Analyse coût-efficacité de programmes de prévention de l’exposition au radon en Franche-Comté

Contexte : Le radon est le second carcinogene pulmonaire apres le tabagisme. Certaines mesures dans l’habitat peuvent reduire l’exposition de la population. Notre etude portait sur une analyse cout-efficacite des politiques anti-radon en Franche-Comte, region francaise particulierement exposee. Les strategies evaluees etaient le depistage cible en zones a risque et le depistage de masse, compares a l’absence de depistage.Methodes : Un modele de Markov a ete construit pour simuler les effets d’un depistage de l’exposition au radon chez une population âgee de 30 a 75 ans pendant 30 ans. Pour chaque strategie, les parametres d’efficacite etaient l’esperance de vie moyenne, l’incidence de cancer pulmonaire induit par le radon et le nombre de deces associe. Les couts consideres etaient des couts directs correspondant a l’invitation au depistage, la mesure de l’exposition, la remediation au diagnostic de cancer pulmonaire et au traitement. Les ratios cout-efficacite incrementiels estimes correspondaient au cout par annee de vie gagnee, au cout par cancer evite et au cout par deces evite. Le taux d’actualisation utilise etait de 3 %.Resultats : Le nombre d’annees de vie gagnees par individu etait de 8x10-6 pour le depistage cible et de 2,1x10-5 pour le depistage de masse. Le nombre annuel moyen de cancers pulmonaires induits par le radon en Franche-Comte etait de 71,4 en l’absence de depistage, de 71,3 avec le depistage cible et de 70,6 avec le depistage de masse. Les nombres de deces associes etaient respectivement de 65,4, de 65,3 et de 64,7. Les couts par annee de vie gagnee etaient de 295,105 € pour le depistage cible et de 987,108 € pour le depistage de masse comparativement a l’absence de depistage.Conclusions : Les depistages cibles comme de masse ne sont pas cout-efficaces. Il semble plus pertinent de concentrer la lutte contre le cancer pulmonaire induit par le radon sur des mesures de prevention dans l’habitat neuf.

Cost of pretherapeutic staging of patients with colorectal cancer metastases in a French population.

BACKGROUND Little is known about the economic burden of pretherapeutic staging of patients presenting colorectal cancer metastases. OBJECTIVE The aim of this study was to estimate the cost of pretherapeutic staging and identify cost determinants for 132 patients presenting colorectal metastases and living in the north-east of France. METHOD Staging cost was estimated using direct medical costs from the point of view of the French Health Insurance System. Independent factors were identified using a linear regression model, and bootstrap resampling was used to estimate unbiased standard errors and 95% confidence intervals. RESULTS The overall mean cost for pretherapeutic staging was estimated to be 1534€ [95% CI: 1250€-1818€]. Staging costs increased significantly with the number of medical procedures performed during the staging, and according to health care patterns (in-patient hospital stay versus out-patient episodes, public versus private care). CONCLUSION These results could now be used to estimate the impact of new imaging techniques on clinical practices and pretherapeutic staging costs.