Rapid review of existing literature on the cost effectiveness of alternative systems for diagnosis and referral of any cancer in primary care

Introduction: A rapid review has been conducted to explore the existing literature on the cost-effectiveness of interventions/strategies for diagnosis and referral of patients with symptoms that might be suspected for cancer. The aim of the review was to assess whether existing literature could be useful in informing UK policy in these areas.

Methods: A systematic literature search was undertaken that considered for inclusion all economic evaluations in the subject areas described above. Data extracted included details of condition (type of cancer) examined, study design, findings (including incremental cost-effectiveness ratios (ICERs), assessment of uncertainty) and quality assessment. In order to maximise the usefulness of this report, papers deemed of high quality represented the priority for discussion. However, data extracted from all papers meeting the inclusion criteria have been presented in an Appendix. Further appendices describe the search strategy methods, results and individual abstracts. Subsequently, interventions/strategies were assessed for their relevance to UK policy and decision making by a group of clinical experts in the relevant fields.

Results: The search identified 1,478 references. After excluding papers that were duplicates, non-English language, not economic evaluations, not focussed on cancer or not related to diagnosis/referral for symptoms potentially related to cancer, 28 were finally identified as potentially relevant. These articles were ordered or retrieved from the web. After exclusion of non-relevant studies based on examination of full text, a total of 16 articles were included in the analysis.

Conclusions: Cervical cancer was the most common (n=4) cancer type in these studies. Breast (n=2), colorectal (n=2), gastro-oesophageal (n=2), back pain related to cancer (n=2), skin (n=1), lung (n=1), hepatocellular (n=1) and endometrial (n=1) were also studied. The higher quality studies and expert opinion suggested the following:

Cervical

• In the UK, referral to colposcopy after one mild result during cervical screening rather than after two consecutive mild results appears a cost-effective option.

• Published studies suggest that the addition of HPV triage to standard repeat of Pap smear for women with ASC-US might provide good value for money, but that this is already implemented in the NHS

Colorectal

• Colonoscopy might be the most cost-effective strategy in patients presenting to their GP with rectal bleeding compared to other diagnostic options as sigmoidoscopy or watchful waiting.

• Immediate colonoscopy could lead to cost savings compared to a traditional system of “waiting list” for colonoscopy.

Breast

• Immediate fine needle aspiration cytology (FNAC) appears a cost-effective option for patients with a suspicious lesion identified with mammography and clinical examination, and this is fairly routine in the NHS.

Low back pain related

• Magnetic resonance imaging (MRI) might not be a cost-effective option for patients with low-back pain related to cancer and implementation would likely cause capacity problems in primary care.

Gastro-oesophageal

• Performing early endoscopy in all patients presenting with dyspepsia would lead to very large costs per malignancy detected.

• Endoscopy appears a cost-effective option only in a selected subgroup of patients, namely those considered “appropriate” on the basis of American Society of Gastrointestinal Endoscopy (ASGE) or European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) guidelines.

The suggestions described above should be interpreted with caution. Some of the studies were not UK based, several were dated and there was limited evidence that all relevant data had been synthesised or considered. In addition, the relevance of the comparators included may be questioned. Subsequent evidence from expert clinicians indicates that, where there was a demonstrably cost-effective intervention or strategy, this is often in place in the UK NHS setting.