In an ideal world, everyone would have access to any health care needed to prevent disease, catch it early, or treat it in the longer term.
But in the real world, we sometimes must make choices about how to do the most good with limited resources when we can't do everything.
These kinds of tradeoffs are at the heart of new research from Uri Ladabaum, MD. The Stanford professor of medicine is the lead author of a study that models the effects of a 2018 American Cancer Society recommendation to begin colorectal cancer screening at age 45 rather than age 50 for people at average risk.
Ladabaum and his colleagues find that such a move would save lives and be cost-effective, but that screening more older and higher-risk people instead would have greater societal benefit at lower cost. The paper, published online today in Gastroenterology, will be presented at the Digestive Disease Week conference in San Diego in May.
As I wrote in the news release:
The study found that over the next five years, initiating testing at age 45 could reduce the number of cancer cases by as many as 29,400 and deaths by up to 11,100, at an added societal cost of $10.4 billion. An additional 10.6 million colonoscopies would be required.
By comparison, increasing screening participation to 80 percent of 50- to 75-year-olds would reduce cases by 77,500 and deaths by 31,800 at an added cost of only $3.4 billion, according to the model. The number of additional colonoscopies needed would be 12 million.
To be sure, the American Cancer Society's decision to change the guideline didn't come out of the blue: it's meant to address a rise in colorectal cancer in younger people, including a worrying 22 percent increase in incidence rates for those in their 40s. Other groups, including the U.S. Preventive Services Task Force, are also considering the move. The fact that physicians haven't yet pinpointed exactly why this is happening -- whether it's attributable to obesity, diet or some combination of factors -- adds to the consternation.
"It can get emotional and passionate," Ladabaum, who directs the gastrointestinal cancer prevention program at Stanford Health Care, says in the release, "because death from cancer at a young age is particularly devastating."
Still, as the study notes, incidence of colorectal cancer continues to be considerably higher for people older than 50, and the percentage of them participating in screening is sub-optimal, hovering around 60 percent rather than 80 percent as health professionals would prefer.
Using their model, Ladabaum and his colleagues compared potential costs and benefits of allocating screening resources differently. He says:
If we actually do face tradeoffs on the societal level, either in terms of the effort we can put into this or the supply of colonoscopies and the distribution of colonoscopies by geography, then one can debate whether the efforts should go toward now bringing in younger people or whether we should focus on older people... If we can bring in everybody, great. But if not, screening older and higher-risk people is higher yield in terms of public health benefit.
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