David K. Whynes

Prevention of colorectal cancer by once-only sigmoidoscopy

There is no national screening programme for colorectal cancer in the UK despite the fact that the annual death toll from this disease exceeds that of breast and cervical cancer. Faecal occult blood testing (FOBT) is under evaluation for screening, but screening by sigmoidoscopy is not considered viable. This situation contrasts with the USA where both annual FOBT and screening by flexible sigmoidoscopy every 3 to 5 years are recommended from 50 years old. We seek to demonstrate that most of the benefit from the US screening policy would accrue from a single flexible sigmoidoscopy examination at age 55 to 60 years with appropriate colonoscopic surveillance for the 3% to 5% found to have high-risk adenomas (> or = 1 cm or villous histology). If applied nationally, this screening regimen could prevent about 5500 colorectal cancer cases and 3500 deaths in the UK each year, thus saving 40,000 years of life. We estimate that there would be little net cost to the National Health Service because savings obtained from treating fewer patients would largely offset the cost of screening. We recommend that a randomised trial to evaluate screening by single flexible sigmoidoscopy should start without delay. Such a trial would involve about 120,000 participants, and 15 years of follow-up would be required to obtain a clear answer on mortality, although information on incidence reduction would be available sooner.

Nottingham trial of faecal occult blood testing for colorectal cancer: a 20-year follow-up

Background Three large randomised trials have shown that screening for colorectal cancer (CRC) using the faecal occult blood test (FOBt) can reduce the mortality from this disease. The largest of these trials, conducted in Nottingham since 1981, randomised 152 850 individuals between the ages of 45 and 74 years to an intervention arm receiving biennial Haemoccult (FOB) test kit or to a control arm. In 2006, the National Bowel Cancer Screening Programme was launched in England using the FOBt, with the expectation that it will reduce CRC mortality. Aims To compare the CRC mortality and incidence in the intervention arm with the control arm after long-term follow-up. Methods The 152 850 randomised individuals were followed up through local health records and central flagging (Office for National Statistics). Results At a median follow-up of 19.5 years there was a 13% reduction in CRC mortality (95% CI 3% to 22%) in the intervention arm despite an uptake at first invitation of approximately 57%. The CRC mortality reduction in those accepting the first screening test, adjusted for the rate of non-compliers, was 18%. There was no significant difference in mortality from causes other than CRC between the intervention and control arms. Despite removing 615 adenomas >10 mm in size from the intervention arm, there was no significant difference in CRC incidence between the two arms. Conclusions Although the reduction in CRC mortality was sustained, further follow-up of the screened population has not shown a significant reduction in the CRC incidence. Moreover, despite the removal of many large adenomas there was no reduction in the incidence of invasive cancer which was independent of sex and site of the tumour.

Cost effectiveness analysis of intensive versus conventional follow up after curative resection for colorectal cancer.

Abstract Objective To determine the cost effectiveness of intensive follow up compared with conventional follow up in patients with colorectal cancer. Design Incremental cost effectiveness analysis recognising differences in follow up strategies, based on effectiveness data from a meta-analysis of five randomised trials. Setting United Kingdom. Main outcome measures Taking a health service perspective, estimated incremental costs effectiveness ratios for each life year gained for five trials and four trials designed for early detection of extramural recurrences (targeted surveillance). Results Based on five year follow up, the numbers of life years gained by intensive follow up were 0.73 for the five trial model and 0.82 for the four trial model. For the five trials, the adjusted net (extra) cost for each patient was £2479 (€3550;

What does a University add to its local economy

4288) and for each life year gained was £3402, substantially lower than the current threshold of NHS cost acceptability (£30 000). The corresponding values for the four trial model were £2529 and £3077, suggesting that targeted surveillance is more cost effective. The main predictor of incremental cost effectiveness ratios was surveillance costs rather than treatment costs. Judged against the NHS threshold of cost acceptability, the predicted incremental cost threshold was ninefold and the effectiveness threshold was 3%. Conclusions Based on the available data and current costs, intensive follow up after curative resection for colorectal cancer is economically justified and should be normal practice. There is a continuing need to evaluate the efficacy of specific surveillance tools: this study forms the basis for economic evaluations in such trials.

Eliciting Willingness to Pay: Comparing Closed-Ended with Open-Ended and Payment Scale Formats

The local multiplier effects of a university are estimated using data for the University of Nottingham. Gross output and disposable income multipliers are calculated. The latter are adjusted to exclude the incomes of induced migrants, whose welfare is assumed unchanged.

Colorectal cancer, screening and survival: the influence of socio-economic deprivation

Willingness to pay (WTP) is increasingly being used as a measure of valuation in health technology assessment. A variety of formats for eliciting values are available, although the relative virtues of each remain the subject of methodological controversy. This article compares valuation results obtained using a WTP survey instrument in a closed-ended format with those obtained from instruments using open-ended and payment scale formats. Samples of subjects were drawn from a general population, and all were asked to value the same intervention—alternative methods of screening for colorectal cancer. It was discovered that, whereas the open-ended and payment scale formats produced broadly similar valuations, the closed-ended format produced significantly higher WTP valuations and different justifications for those valuations. It is hypothesized that anchoring and yea-saying effects explain these differences and that the closed-ended format triggers a different response mode in subjects.

Paediatric cochlear implantation: the views of parents

OBJECTIVES To determine the extent to which socio-economic deprivation explains colorectal cancer prevalence, subject participation in screening, and postoperative survival and life expectancy. METHODS Regression analyses of clinical data from a large randomized controlled trial, augmented by geographical-based indices of deprivation. RESULTS Deprivation appears to exert no significant impact on colorectal cancer prevalence but is a major factor explaining subject participation in screening. Cancer detection at later stages reduces life expectancy at time of treatment. Females from more-deprived areas have poorer post-treatment life expectancies and survival prospects, independently of their screening behaviour. CONCLUSIONS Screening increases the chances of having a cancer treated at an earlier stage, and treatment at an earlier stage is associated with longer subsequent life expectancy. However, those from more-deprived areas are less likely to accept an invitation to be screened.

Faecal occult blood screening for colorectal cancer: is it cost-effective?

The purpose of this study was to understand the parental perspective on paediatric cochlear implantation over time. Face-to-face semi-structured interviews were conducted with 216 families of children who were implanted at the Nottingham Paediatric Cochlear Implant Programme between 1989 and 2002, and who were attending an appointment during the study period (July 2001–August 2002). The qualitative data revealed that time played an important role in family experiences of paediatric cochlear implantation. Expectations were continually revised throughout the process, as a result of new knowledge and new technological developments. The results show that outcomes are highly individualistic although parents had a shared hope of the implant enabling the child to function in a “hearing world”; that the biggest area of contention is in respect of their childs education; and that parents talked openly about constraints imposed on them by implantation. The vast majority of parents did not regret their decision to proceed with implantation.

Determinants of persistent compliance with screening for colorectal cancer

Recently published evidence from two large-scale clinical trials conducted in England and in Denmark suggests that faecal occult blood screening for colorectal cancer significantly reduces mortality. However, before screening can be advocated as part of national health policy, its cost-effectiveness must be demonstrated. The English screening trial has been the subject of a detailed economic evaluation over the past 10 years In this paper, cost-effectiveness estimates of screening are presented, based on cost and outcome data combined in a mathematical model developed from the trials clinical findings The estimates of cost per quality-adjusted life-year gained from colorectal cancer screening show the procedure to be of similar cost-effectiveness to breast cancer screening in the short term. Over the longer term, however, the estimates for colorectal cancer screening appear superior.

UK Lung Cancer RCT Pilot Screening Trial: baseline findings from the screening arm provide evidence for the potential implementation of lung cancer screening

Mass population screening for colorectal cancer is currently being evaluated by means of randomized controlled trials. These trials point to the likelihood that, if implemented, the level of both initial and sustained compliance will prevent the full potential of screening being realised. The paper opens by reviewing the evidence on determinants of compliance, both initial and longer term, although little empirical evidence on adherence to repeated screening is currently available. The paper then presents the results of a survey of persistent compliers and non-compliers within the English screening trial, in order to identify those characteristics most closely associated with persistent compliance behaviour. Persistent compliers are found, inter alia, to be of higher socio-economic classes than persistent non-compliers, to have more personal and family experiences of illness and to visit their dentists more regularly. The results suggest that generalized attempts at compliance enhancement would be ineffectual against the prevailing background characteristics of the non-compliant population, and that the more overt targeting of efforts in this respect is to be preferred.