Colonoscopy Screening for Ulcerative Colitis: Cost-Effectiveness
Introduction
Ulcerative colitis (UC), a chronic disease impacting the large intestine. It is becoming increasingly prevalent, not just globally, but also specifically in Saudi Arabia. Individuals with long-standing UC are at a higher risk of developing colorectal cancer (CRC), a serious complication associated with inflammatory bowel disease (IBD). With the potential risk of CRC in UC patients being 1.7 times higher than the general population, it is crucial to establish effective and cost-effective screening methods.
The Controversy Surrounding Surveillance Colonoscopy
Surveillance colonoscopy, a method used to detect dysplasia in UC patients, has been shown to be effective in reducing CRC rates. Yet, there is ongoing debate about the cost-effectiveness of this screening method. While some studies suggest that surveillance can increase life expectancy, others argue that it may not always be cost-effective. Especially in the Middle Eastern context, this is observed.
The Saudi Scenario
A recent study focused on the cost-consequence analysis of annual colonoscopy surveillance among high-risk UC patients in Saudi Arabia. The findings revealed that this practice results in higher costs but lower rates of dysplasia detection. They found that each 1% reduction in dysplasia rates was associated with an incremental cost of USD 740.125. If we assume that a 50% decrease in high grade dysplasia rates will lead to at least one extra quality-adjusted life year (QALY), then the USD 37,006.25 (50 times USD 740.125) is more than the recently released cost-effectiveness threshold for Saudi Arabia, which is USD 20,183 per QALY.
Limitations of Annual Screening
The cost-effectiveness of annual colonoscopy screening among high-risk UC patients in the Middle Eastern population is yet to be reported. A systematic review found that all CRC screening techniques were more cost-effective than no screening at different cost-effectiveness criteria. Although a colonoscopy every 10 years was cost-effective, most trials reported greater costs than no screening, and ICERs exceeded USD 20,000 in several cases. Furthermore, the discomfort associated with colonoscopy and the lack of endoscopic capacity in Saudi Arabia make annual colonoscopy screening not just cost-ineffective but inconvenient to patients and the healthcare system.
Potential AI Intervention
The potential of artificial intelligence (AI) in screening CRC is worth investigating. A study examining the adoption of AI in colonoscopy for CRC screening resulted in a significant reduction in CRC incidence (8.4 %) and mortality (6.9 %), suggesting a promising direction for future research.
The Role of Albumin Levels
The study also revealed that patients who had higher albumin levels were less likely to have dysplasia compared to those with hypoalbuminemia. This finding is consistent with another study that examined the use of albumin as a prognostic marker for ulcerative colitis.
Concluding Thoughts
Adherence to annual colonoscopy for CRC screening has resulted in higher rates of dysplasia detection among long-standing UC patients. However, this comes with a significant incremental cost. Based on recent findings, performing colonoscopy for CRC screening on an annual basis is likely to be inefficient. Thus, longitudinal prospective cohort studies should examine the cost-effectiveness of various CRC screening strategies, including 5-year and 10-year colonoscopies.
