A review of the Nottingham faecal occult blood (FOBT) screening trial and its associated economic evaluations
aDivision of GI Surgery, Queens Medical Centre, Nottingham, United Kingdom, bDepartment of Economics, University of Nottingham, Nottingham, United Kingdom
Aim: The results of the Nottingham FOBT screening trial have been reported previously. This focus lecture reviews the results of this large randomised trial and discusses the findings of the associated economic evaluations. This talk will be relevant to all those interested in screening for malignancy while providing an important economic perspective to establishing a national screening program. Methods: The Nottingham FOBT trial recruited patients aged 45-74 years, from February 1981 to January 1991. Participants were randomly allocated to FOB screening (76466) or no screening (controls; 76384) and it remains one of the largest trials of its kind, with a median follow-up of 11 years. Those with positive tests were offered colonoscopic investigation. Screening was stopped in February 1995, by which time screening-group participants had been offered FOB tests between three and six times. Non-rehydrated Haemoccult FOB tests were used for most tests. Results: Initial results were published in 1996 and the follow-up figures recently published show a 13% reduction in colorectal cancer mortality (95% confidence interval 3-22%) in the intervention group. The mortality reduction for those accepting screening was 27%. Initial analyses involved the calculation of resource costs (the cost of running such a screening program in a real-world context). This was found to be £2700 (US$ 4509) per cancer detected or £5.30 (US$ 8.85) per person screened. Sensitivity analysis revealed that programme costs were more sensitive to clinical variables such as compliance or detection rates, than they were to the costs of the resource inputs. Cost-effectiveness analysis using a semi-Markov framework recorded an incremental cost effectiveness ratio of approximately £5700 (US$ 9519) per quality adjusted life year (QALY). Conclusions: The Nottingham FOBT screening trial showed a 13% reduction in colorectal cancer mortality in the intervention group. Concurrent economic evaluations have found screening for colorectal cancer with this test, to be at least as cost-effective as breast and cervical screening, both of which are well established in the United Kingdom (UK). Within the UK, there remains considerable debate regarding the most appropriate screening tool and frequency of screening, combined with concerns regarding the logistics of providing such a service.
Paper presented at the International Symposium on Predictive Oncology and Intervention Strategies; Nice, France; February 7 - 10, 2004; in poster session 992 (Screening & detection).