Cost-Effectiveness of Colorectal Cancer Surveillance in Hodgkin Lymphoma Survivors Treated with Procarbazine and/or Infradiaphragmatic Radiotherapy

Berbel L.M. Ykema, Andrea Gini, DICHOS study group, Lisanne S. Rigter, Manon C.W. Spaander, Leon M.G. Moons, Tanya M. Bisseling, Jan Paul de Boer, Wieke H.M. Verbeek, Pieternella J. Lugtenburg, Cecile P.M. Janus, Eefke J. Petersen, Judith M. Roesink, Richard W.M. van der Maazen, Berthe M.P. Aleman, Gerrit A. Meijer, Flora E. van Leeuwen, Petur Snaebjornsson, Beatriz Carvalho, Monique E. van LeerdamIris Lansdorp-Vogelaar*

*Corresponding author for this work

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Background: Hodgkin lymphoma survivors treated with infradiaphragmatic radiotherapy (IRT) and/or procarbazine have an increased risk of developing colorectal cancer. We investigated the cost-effectiveness of colorectal cancer surveillance in Dutch Hodgkin lymphoma survivors to determine the optimal surveillance strategy for different Hodgkin lymphoma subgroups. Methods: The Microsimulation Screening Analysis-Colon model was adjusted to reflect colorectal cancer and other-cause mortality risk in Hodgkin lymphoma survivors. Ninety colorectal cancer surveillance strategies were evaluated varying in starting and stopping age, interval, and modality [colonoscopy, fecal immunochemical test (FIT, OC-Sensor; cutoffs: 10/20/47 mg Hb/g feces), and multi-target stool DNA test (Cologuard)]. Analyses were also stratified per primary treatment (IRT and procarbazine or procarbazine without IRT). Colorectal cancer deaths averted (compared with no surveillance) and incremental cost-effectiveness ratios (ICER) were primary outcomes. The optimal surveillance strategy was identified assuming a willingness-to-pay threshold of €20,000 per life-years gained (LYG). Results: Overall, the optimal surveillance strategy was annual FIT (47 mg) from age 45 to 70 years, which might avert 70% of colorectal cancer deaths in Hodgkin lymphoma survivors (compared with no surveillance; ICER:€18,000/LYG). The optimal surveillance strategy in Hodgkin lymphoma survivors treated with procarbazine without IRT was biennial FIT (47 mg) from age 45 to 70 years (colorectal cancer mortality averted 56%; ICER:€15,000/LYG), and when treated with IRT and procarbazine, annual FIT (47 mg) surveillance from age 40 to 70 was most cost-effective (colorectal cancer mortality averted 75%; ICER:€13,000/LYG). Conclusions: Colorectal cancer surveillance in Hodgkin lymphoma survivors is cost-effective and should commence earlier than screening occurs in population screening programs. For all subgroups, FIT surveillance was the most cost-effective strategy. Impact: Colorectal cancer surveillance should be implemented in Hodgkin lymphoma survivors.

Bibliographical note

Funding Information:
M.C.W. Spaander reports other support from Sysmex, Sentinel; and other support from Norgine outside the submitted work. L.M.G. Moons reports Consultant for Boston Scientific. P.J. Lugtenburg reports grants from Takeda, Servier; personal fees from Celgene, Genmab, Roche, AbbVie, Incyte; and personal fees from Regeneron outside the submitted work. G.A. Meijer reports nonfinancial support from Exact Sciences, Sysmex, Sentinel Ch.SpA, Personal Genome Diagnostics (PGDX), Hartwig Medical Foundation; grants from CZ (OWM Centrale Zorgverzekeraars groep Zorgverzekeraar u.a); and nonfinancial support from DELFi outside the submitted work; in addition, G.A. Meijer has a patent for Several pending; and GA Meijer is cofounder and board member (CSO) of colorectal cancer bioscreen BV. P. Snaeb-jornsson reports other support from MSD, Bayer; and other support from MEDtalks outside the submitted work. B. Carvalho reports a patent for Protein biomarkers for detection of colorectal cancer licensed to NL 2008707;EP13720130.7;14/396,522;NL 2010276;PCT/NL13/50316;15/444,679;EP19201973.5, a patent for Protein biomar- kers (II) for detection of colorectal cancer in stool licensed to 17172531.0;2017-009-02;2017-009-03;2017-009-04;2017-009-05;2017-009-06, and a patent for Progression markers for colorectal cancer licensed to EP19187894.1;PCT/NL2020/050482. M.E. van Leerdam reports grants from the Dutch Society of Gastroenterology and Hepatology (Maag Lever Darm Stichting (MLDS) funding project FP14-04 outside the submitted work. No disclosures were reported by the other authors.

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