Acknowledging patient heterogeneity in colorectal cancer screening: An example from Norway


  • Mathyn A.M. Vervaart
  • Emily A. Burger
  • Eline Aas Institute of Health and Society, Department of Health Management and Health Economics, University of Oslo Postboks 1089, Blindern 0317 Oslo Norway



Patient heterogeneity, stratified analysis, cost-effectiveness, screening for colorectal cancer


Abstract: Different sources of patient heterogeneity or personal characteristics may contribute to differential cost-effectiveness profiles of national screening programs for colorectal cancer (CRC). To motivate the use of subgroup analyses when individual level data are unavailable, we provide a stylized example of the potential economic value of capturing patient heterogeneity in CRC screening. We developed a Markov model to capture the impacts of patient heterogeneity on the cost-effectiveness of CRC screening involving once-only sigmoidoscopy compared to no screening. We simulated cohorts of Norwegian men, women, and six comorbidity subgroups that differentially influenced the relative treatment effect, the risks of developing CRC, dying from CRC, dying from background mortality or screening-related adverse events and baseline quality of life. We calculated the discounted (4%) incremental cost-effectiveness ratio (ICER), defined as the cost per quality-adjusted life year (QALY) gained, and the net monetary benefit (NMB) gained by stratification, from a societal perspective. Screening in men was cost-effective at any threshold value, while screening in women only provides good value for money from threshold values of €50,000 per QALY gained and above. Comorbidities unrelated to CRC development yielded generally less attractive cost-effectiveness ratios (i.e., increased the ICER), while related comorbidities improved the cost-effectiveness profiles of screening for CRC. A stratified policy that accounts for different screening outcomes between men and women could potentially improve the value of screening by €5.8 million annually. Accounting for patient heterogeneity in CRC screening will likely improve the value of screening strategies, as a single screening approach for the entire population can result in inefficient use of resources.

Published: Online December 2018.