Hostname: page-component-586b7cd67f-2brh9 Total loading time: 0 Render date: 2024-11-25T19:27:52.288Z Has data issue: false hasContentIssue false
  • English
  • Français

Can calcium chemoprevention of adenoma recurrence substitute or serve as an adjunct for colonoscopic surveillance?

Published online by Cambridge University Press:  31 March 2009

Aasma Shaukat ,
Murtaza Parekh ,
Joseph Lipscomb  and
Uri Ladabaum
Aasma Shaukat
Affiliation:
University of Minnesota
Murtaza Parekh
Affiliation:
University of California, San Francisco
Joseph Lipscomb
Affiliation:
Emory University
Uri Ladabaum
Affiliation:
University of California, San Francisco
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives: The aim of this study was to examine the potential cost-effectiveness of calcium chemoprevention post-polypectomy as a substitute or adjunct for surveillance.

Methods: We constructed a Markov model of post-polypectomy adenoma recurrence and colorectal cancer (CRC) development, calibrated to data from prospective chemoprevention trials of fiber, calcium, antioxidants, and aspirin. We modeled four scenarios for 50-year-old patients immediately after polypectomy: (i) natural history with no further intervention; (ii) elemental calcium 1,200 mg/day from age 50–80; (iii) surveillance colonoscopy from age 50–80 every 5 years, or 3 years for large adenoma; (iv) calcium + surveillance. Patients were followed up until age 100 or death.

Results: Calcium was cost-effective compared to natural history ($49,900/life-year gained). However, surveillance was significantly more effective than calcium (18.729 versus 18.654 life-years/patient; 76 percent versus 14 percent reduction in CRC incidence) at an incremental cost of $15,900/life-year gained. Calcium + surveillance yielded a very small benefit (0.0003 incremental life-years/patient) compared with surveillance alone, at a substantial incremental cost of $3,090,000/life-year gained.

Conclusion: Post-polypectomy calcium chemoprevention is unlikely to be a reasonable substitute for surveillance. It may be cost-effective in patients unwilling or unable to undergo surveillance.

Keywords

CalciumChemopreventionColorectal cancer
Type
General Essays
Information
International Journal of Technology Assessment in Health Care , Volume 25 , Issue 2 , April 2009 , pp. 222 - 231
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Alberts, DS, Martinez, ME, Roe, DJ et al. , Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas. Phoenix Colon Cancer Prevention Physicians’ Network. N Engl J Med. 2000;342:1156–1162.CrossRefGoogle ScholarPubMed
2. Anderson, WF, Umar, A, Viner, JL, Hawk, ET. The role of cyclooxygenase inhibitors in cancer prevention. Curr Pharm Des. 2002;8:1035–1062.CrossRefGoogle ScholarPubMed
3. Arguedas, MR, Heudebert, GR, Wilcox, CM. Surveillance colonoscopy or chemoprevention with COX-2 inhibitors in average-risk post-polypectomy patients: A decision analysis. Aliment Pharmacol Ther. 2001;15:631–638.CrossRefGoogle ScholarPubMed
4. Baron, JA, Beach, M, Mandel, JS et al. , Calcium supplements for the prevention of colorectal adenomas. Calcium Polyp Prevention Study Group [see comment]. N Engl J Med. 1999;340:101–107.CrossRefGoogle ScholarPubMed
5. Baron, JA, Cole, B F, Sandler, RS et al. , A randomized trial of aspirin to prevent colorectal adenomas [see comment]. N Engl J Med. 2003;348:891–899.CrossRefGoogle ScholarPubMed
6. Bond, JH. Clinical evidence for the adenoma-carcinoma sequence, and the management of patients with colorectal adenomas. Semin Gastrointest Dis. 2000;11:176–184.Google ScholarPubMed
7. Bond, JH. Polyp guideline: Diagnosis, treatment, and surveillance for patients with colorectal polyps. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 2000;95:3053–3063.CrossRefGoogle ScholarPubMed
8. Bonithon-Kopp, C, Piard, F, Fenger, C et al. , Colorectal adenoma characteristics as predictors of recurrence. Dis Colon Rectum. 2004;47:323–333.CrossRefGoogle ScholarPubMed
9. Brown, ML, Riley, GF, Potosky, AL, Etzioni, RD. Obtaining long-term disease specific costs of care: Application to Medicare enrollees diagnosed with colorectal cancer. Med Care. 1999;37:1249–1259.CrossRefGoogle ScholarPubMed
10. Buckley, LM, Hillner, BE. A cost effectiveness analysis of calcium and vitamin D supplementation, etidronate, and alendronate in the prevention of vertebral fractures in women treated with glucocorticoids [see comment]. J Rheumatol. 2003;30:132–138.Google ScholarPubMed
11. Cotton, S, Sharp, L, Little, J. The adenoma-carcinoma sequence and prospects for the prevention of colorectal neoplasia. Crit Rev Oncog. 1996;7:293–342.CrossRefGoogle ScholarPubMed
12. Eddy, DM. Screening for colorectal cancer. Ann Intern Med. 1990;113:373–384.CrossRefGoogle ScholarPubMed
13. Eddy, DM, Nugent, FW, Eddy, JF et al. , Screening for colorectal cancer in a high-risk population. Results of a mathematical model. Gastroenterology. 1987;92:682–692.CrossRefGoogle Scholar
14. Fireman, BH, Quesenberry, CP, Somkin, CP et al. , Cost of care for cancer in a health maintenance organization. Health Care Financ Rev. 1997;18:51–76.Google Scholar
15. Frazier, AL, Colditz, GA, Fuchs, CS, Kuntz, KM. Cost-effectiveness of screening for colorectal cancer in the general population. JAMA. 2000;284:1954–1961.CrossRefGoogle ScholarPubMed
16. Giovannucci, E. Modifiable risk factors for colon cancer. Gastroenterol Clin North Am. 2002;31:925–943.CrossRefGoogle ScholarPubMed
17. Grau, MV, Baron, JA, Barry, EL et al. , Interaction of calcium supplementation and nonsteroidal anti-inflammatory drugs and the risk of colorectal adenomas. Cancer Epidemiol Biomarkers Prev. 2005;14:2353–1258.CrossRefGoogle ScholarPubMed
18. Greenberg, ER, Baron, JA, Tosteson, TD et al. , A clinical trial of antioxidant vitamins to prevent colorectal adenoma. Polyp Prevention Study Group. N Engl J Med. 1994;331:141–147.CrossRefGoogle ScholarPubMed
19. Greenlee, RT, Murray, T, Bolden, S, Wingo, PA. Cancer statistics, 2000. CA Cancer J Clin. 2000;50:7–33.CrossRefGoogle ScholarPubMed
20. Hawk, ET, Limburg, PJ, Viner, JL. Epidemiology and prevention of colorectal cancer. Surg Clin North Am. 2002;82:905–941.CrossRefGoogle ScholarPubMed
21. Heaney, RP, Dowell, MS, Bierman, J, Hale, CA, Bendich, A. Absorbability and cost effectiveness in calcium supplementation. J Am Coll Nutr. 2001;20:239–246.CrossRefGoogle ScholarPubMed
22. Itzkowitz, SH. Gastrointestinal adenomatous polyps. Semin Gastrointest Dis. 1996;7:105–116.Google ScholarPubMed
23. Keller, JL, Lanou, A, Barnard, ND. The consumer cost of calcium from food and supplements. J Am Diet Assoc. 2002;102:1669–1671.CrossRefGoogle ScholarPubMed
24. Khandker, RK, Dulski, JD, Kilpatrick, JB et al. , A decision model and cost-effectiveness analysis of colorectal cancer screening and surveillance guidelines for average-risk adults. Int J Technol Assess Health Care. 2000;16:799–810.CrossRefGoogle ScholarPubMed
25. Ladabaum, U, Chopra, CL, Huang, G et al. , Aspirin as an adjunct to screening for prevention of sporadic colorectal cancer. A cost-effectiveness analysis. Ann Intern Med. 2001;135:769–781.CrossRefGoogle ScholarPubMed
26. Ladabaum, U, Scheiman, JM, Fendrick, AM. Potential effect of cyclooxygenase-2-specific inhibitors on the prevention of colorectal cancer: A cost-effectiveness analysis. Am J Med. 2003;114:546–554.CrossRefGoogle ScholarPubMed
27. Ladabaum, U, Song, K. Projected national impact of colorectal cancer screening on clinical and economic outcomes and health services demand [see comment]. Gastroenterology. 2005;129:1151–1162.CrossRefGoogle ScholarPubMed
28. Ladabaum, U, Song, K, Fendrick, AM. Colorectal neoplasia screening with virtual colonoscopy: When, at what cost, and with what national impact? Clin Gastroenterol Hepatol. 2004;2:554–563.CrossRefGoogle ScholarPubMed
29. Lamprecht, SA, Lipkin, M. Chemoprevention of colon cancer by calcium, vitamin D and folate: Molecular mechanisms. Nat Rev Cancer. 2003;3:601–614.CrossRefGoogle ScholarPubMed
30. Levenson, DI, Bockman, RS. A review of calcium preparations [erratum appears in Nutr Rev. 1994;52:364]. Nutr Rev. 1994;52:221–232.CrossRefGoogle ScholarPubMed
31. Lipkin, M. Early development of cancer chemoprevention clinical trials: Studies of dietary calcium as a chemopreventive agent for human subjects. Eur J Cancer Prev. 2002;11 (Suppl 2):S65–S70.Google ScholarPubMed
32. Lipkin, M, Reddy, B, Newmark, H, Lamprecht, SA. Dietary factors in human colorectal cancer. Annu Rev Nutr. 1999;19:545–586.CrossRefGoogle ScholarPubMed
33. Martinez, ME, Sampliner, R, Marshall, JR et al. , Adenoma characteristics as risk factors for recurrence of advanced adenomas. Gastroenterology. 2001;120:1077–1083.CrossRefGoogle ScholarPubMed
34. Martinez, ME, Willett, WC. Calcium, vitamin D, and colorectal cancer: A review of the epidemiologic evidence. Cancer Epidemiol Biomarkers Prev. 1998;7:163–168.Google ScholarPubMed
35. Morson, BC. The evolution of colorectal carcinoma. Clin Radiol. 1984;35:425–431.CrossRefGoogle ScholarPubMed
36. National Center for Health Statistics. Preprint of Volume II, Mortality, Part A, Section 6 Life Tables. Hyattsville, MD: National Center for Health Statistics; 1998.Google Scholar
37. Neugut, AI, Jacobson, JS, Ahsan, H et al. , Incidence and recurrence rates of colorectal adenomas: A prospective study. Gastroenterology. 1995;108:402–408.CrossRefGoogle ScholarPubMed
38. Noshirwani, KC, van Stolk, RU, Rybicki, LA, Beck, GJ. Adenoma size and number are predictive of adenoma recurrence: Implications for surveillance colonoscopy. Gastrointest Endosc. 2000;51 (pt 1):433–437.CrossRefGoogle ScholarPubMed
39. Parkin, DM, Bray, F, Ferlay, J, Pisani, P. Estimating the world cancer burden: Globocan 2000. Int J Cancer. 2001;94:153–156.CrossRefGoogle ScholarPubMed
40. Parkin, DM, Pisani, P, Ferlay, J. Global cancer statistics. CA Cancer J Clin. 1999;49:33–64.CrossRefGoogle ScholarPubMed
41. Pence, BC. Role of calcium in colon cancer prevention: Experimental and clinical studies. Mutat Res. 1993;290:87–95.CrossRefGoogle ScholarPubMed
42. Pickhardt, PJ, Choi, JR, Hwang, I et al. , Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349:2191–2200.CrossRefGoogle ScholarPubMed
43. Red Book. Montvale: Thomson; 2008:840–843Google Scholar
44. Red Book. Montvale: Thomson; 2005:712–714Google Scholar
45. Rex, DK, Cutler, CS, Lemmel, GT et al. , Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology. 1997;112:24–28.CrossRefGoogle ScholarPubMed
46. Ries, LAG, Kosary, CL, Hankey, B et al. , SEER Cancer Statistics Review, 1973–1994. Bethesda, MD; National Cancer Institute; 1997:17–166.Google Scholar
47. Robertson, DJ, Greenberg, ER, Beach, M et al. , Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology. 2005;129:34–41.CrossRefGoogle ScholarPubMed
48. Rosner, AJ, Grima, DT, Torrance, GW et al. , Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis. Pharmacoeconomics. 1998;14:559–573.CrossRefGoogle ScholarPubMed
49. Sandler, RS, Halabi, S, Baron, JA et al. , A randomized trial of aspirin to prevent colorectal adenomas in patients with previous colorectal cancer [see comment][erratum appears in N Engl J Med. 2003;348:1939]. N Engl J Med. 2003;348;883–890.CrossRefGoogle Scholar
50. Schatzkin, A, Lanza, E, Corle, D et al. , Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Polyp Prevention Trial Study Group. N Engl J Med. 2000;342:1149–1155.CrossRefGoogle ScholarPubMed
51. Schoen, RE. Surveillance after positive and negative colonoscopy examinations: Issues, yields, and use. Am J Gastroenterol. 2003;98:1237–1246.CrossRefGoogle ScholarPubMed
52. Shaukat, A, Scouras, N, Schunemann, HJ. Role of supplemental calcium in the recurrence of colorectal adenomas: A metaanalysis of randomized controlled trials [see comment]. Am J Gastroenterol. 2005;100:390–394.CrossRefGoogle ScholarPubMed
53. Slattery, ML. Diet, lifestyle, and colon cancer. Semin Gastrointest Dis. 2000;11:142–146.Google ScholarPubMed
54. Song, K, Fendrick, AM, Ladabaum, U. Fecal DNA testing compared with conventional colorectal cancer screening methods: A decision analysis. Gastroenterology. 2004;126:1270–1279.CrossRefGoogle ScholarPubMed
55. Sonnenberg, A, Delco, F, Inadomi, JM. Cost-effectiveness of colonoscopy in screening for colorectal cancer. Ann Intern Med. 2000;133:573–584.CrossRefGoogle ScholarPubMed
56. Suleiman, S, Rex, DK, Sonnenberg, A. Chemoprevention of colorectal cancer by aspirin: A cost-effectiveness analysis [see comment]. Gastroenterology. 2002;122:78–84.CrossRefGoogle ScholarPubMed
57. Taplin, SH, Barlow, W, Urban, N et al. , Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care. J Natl Cancer Inst. 1995;87 (6):417–426.CrossRefGoogle ScholarPubMed
58. Terry, P, Baron, JA, Bergkvist, L, Holmberg, L, Wolk, A. Dietary calcium and vitamin D intake and risk of colorectal cancer: A prospective cohort study in women. Nutr Cancer. 2002;43:39–46.CrossRefGoogle ScholarPubMed
59. Vijan, S, Hwang, EW, Hofer, TP, Hayward, RA. Which colon cancer screening test? A comparison of costs, effectiveness, and compliance. Am J Med. 2001;111:593–601.CrossRefGoogle Scholar
60. Wactawski-Wende, J, Kotchen, JM, Anderson, GL et al. , Calcium plus vitamin D supplementation and the risk of colorectal cancer [see comment][erratum appears in N Engl J Med. 2006;354:1102]. N Engl J Med. 2006;354:684–696.CrossRefGoogle Scholar
61. Wagner, JL, Tunis, S, Brown, M, Ching, A, Almeida, R. Cost-effectiveness of colorectal cancer screening in average risk adults. In: Young, G, Rozen, P, Levin, B, eds. Prevention and early detection of colorectal cancer. Philadelphia: Saunders; 1996:321–356.Google Scholar
62. Wegener, M, Borsch, G, Schmidt, G. Colorectal adenomas. Distribution, incidence of malignant transformation, and rate of recurrence. Dis Colon Rectum. 1986;29:383–387.CrossRefGoogle ScholarPubMed
63. Winawer, SJ, Fletcher, RH, Miller, L et al. , Colorectal cancer screening: Clinical guidelines and rationale. Gastroenterology. 1997;112:594–642.CrossRefGoogle ScholarPubMed
64. Winawer, S, Fletcher, R, Rex, D et al. , Colorectal cancer screening and surveillance: Clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003;124:544–560.CrossRefGoogle ScholarPubMed
65. Winawer, SJ, Zauber, AG, Ho, MN et al. , Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329:1977–1981.CrossRefGoogle ScholarPubMed
66. Winawer, SJ, Zauber, AG, O'Brien, MJ et al. , Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med. 1993;328:901–906.CrossRefGoogle ScholarPubMed
67. Zheng, W, Anderson, KE, Kushi, LH et al. , A prospective cohort study of intake of calcium, vitamin D, and other micronutrients in relation to incidence of rectal cancer among postmenopausal women. Cancer Epidemiol Biomarkers Prev. 1998;7:221–225.Google ScholarPubMed
Supplementary material: File

Shaukat supplementary material

figures

Download Shaukat supplementary material(File)
File 36.9 KB
Supplementary material: Image

Shaukat supplementary material

Supplementary figure 1

Download Shaukat supplementary material(Image)
Image 146.5 KB