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January 24/31, 2001

Cost-effectiveness of Colorectal Cancer Screening

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorJody W.ZylkeMD, Contributing EditorIndividualAuthor

JAMA. 2001;285(4):407-408. doi:10.1001/jama.285.4.407

To the Editor: In the cost-effectiveness analysis of colorectal cancer screening by Dr Frazier and colleagues,1 it was reported that "Double-contrast barium enema [DCBE] remained a dominated strategy over a wide range of values for both sensitivity and specificity." However, there are 2 major problems with this statement. First, the values assigned for both the base case and the "plausible ranges of uncertain parameters" do not reflect a thorough review of the literature regarding the accuracy of DCBE. Second, it appears that Frazier et al performed a 1-way sensitivity analysis, which only permits manipulation of 1 variable at a time. If multiple parameters are incorrect, then adjustment for a single variable can still be misleading. Other studies have found DCBE sensitivity to be 40% to 70% for low-risk polyps, 50% to 80% for high-risk polyps, and 80% to 90% for cancer.2,3 Based on my review of the dominant figures within these ranges, I think that the most accurate estimate of DCBE sensitivity for low-risk polyps is 60%; for high-risk polyps, 75%; and for cancer, 85%. In contrast, the base-case figures used in the study were 30%, 50%, and 70%, respectively. Furthermore, the authors used an overall specificity of 86% (range, 80%-98%), which is lower than the more realistic values of 90% for low-risk polyps and 98% for high-risk polyps and cancer.2,3