National Healthcare Quality and Disparities Report
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- Cancer: Cervical Cancer (1)
- (-) Cancer: Colorectal Cancer (26)
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 26 Research Studies DisplayedHassmiller Lich K, O'Leary MC, Nambiar S
Estimating the impact of insurance expansion on colorectal cancer and related costs in North Carolina: a population-level simulation analysis.
Researchers used microsimulation to estimate the health and financial effects of insurance expansion and reduction scenarios in North Carolina (NC) for colorectal cancer screening (CRC). The full lifetime of a simulated population of residents age-eligible for CRC screening (aged 50-75) during a 5-year period were simulated. Findings indicate that the estimated cost savings--balancing increased CRC screening/testing costs against decreased cancer treatment costs--were approximately $30 M and $970 M for Medicaid expansion and Medicare-for-all scenarios, respectively, compared to status quo. The researchers concluded that insurance expansion will likely improve CRC screening both overall and in underserved populations while saving money, with the largest savings realized by Medicare.
AHRQ-funded; HS022981.
Citation: Hassmiller Lich K, O'Leary MC, Nambiar S .
Estimating the impact of insurance expansion on colorectal cancer and related costs in North Carolina: a population-level simulation analysis.
Prev Med 2019 Dec;129s:105847. doi: 10.1016/j.ypmed.2019.105847..
Keywords: Health Insurance, Cancer: Colorectal Cancer, Cancer, Healthcare Costs, Screening, Prevention, Medicaid, Medicare, Policy, Access to Care
Symer MM, Sedrakyan A, Yeo HL
Case sequence analysis of the robotic colorectal resection learning curve.
This study examined trends in the increasing rate of resection surgery for colorectal cancer using robots. It has a major learning curve so investigators wanted to see if complication rates went down as the technology become more common. The cohort included adults undergoing colorectal section from 2008 through 2016 from data in the New York Statewide Planning and Research Cooperative database. The number of procedures started at 76 cases in 2010 and increased to 702 cases in 2015. Findings were that major complications (myocardial infarction, pulmonary embolism, shock, and death) did not decrease but iatrogenic complications were reduced. The odds of prolonged length of stay also decreased over time.
AHRQ-funded; HS000066.
Citation: Symer MM, Sedrakyan A, Yeo HL .
Case sequence analysis of the robotic colorectal resection learning curve.
Dis Colon Rectum 2019 Sep;62(9):1071-78. doi: 10.1097/dcr.0000000000001437..
Keywords: Cancer: Colorectal Cancer, Cancer, Surgery, Education: Continuing Medical Education, Outcomes
Niu X, Amendola LM, Hart R
Clinical exome sequencing vs. usual care for hereditary colorectal cancer diagnosis: a pilot comparative effectiveness study.
The purpose of this study was to evaluate clinical exome sequencing (CES) compared to usual care (UC) in the diagnostic work-up of inherited colorectal cancer/polyposis (CRCP) in a randomized controlled trial (RCT). The investigators indicate that their results suggest that CES provides similar clinical benefits to multi-gene panels in the diagnosis of hereditary CRCP.
AHRQ-funded; HS021686.
Citation: Niu X, Amendola LM, Hart R .
Clinical exome sequencing vs. usual care for hereditary colorectal cancer diagnosis: a pilot comparative effectiveness study.
Contemp Clin Trials 2019 Sep;84:105820. doi: 10.1016/j.cct.2019.105820..
Keywords: Cancer: Colorectal Cancer, Cancer, Diagnostic Safety and Quality, Comparative Effectiveness, Patient-Centered Outcomes Research, Evidence-Based Practice
Emani S, Sequist TD, Lacson R
Ambulatory safety nets to reduce missed and delayed diagnoses of cancer.
An ambulatory safety net (ASN) is an innovative organizational intervention for addressing patient safety related to missed and delayed diagnoses of abnormal test results. ASNs consist of a set of tools, reports and registries, and associated work flows to create a high-reliability system for abnormal test result management. In this paper, two ASNs implemented at an academic medical center are described, one focusing on colon cancer and the other on lung cancer.
AHRQ-funded; HS024722.
Citation: Emani S, Sequist TD, Lacson R .
Ambulatory safety nets to reduce missed and delayed diagnoses of cancer.
Jt Comm J Qual Patient Saf 2019 Aug;45(8):552-57. doi: 10.1016/j.jcjq.2019.05.010.
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Keywords: Cancer, Diagnostic Safety and Quality, Cancer: Lung Cancer, Cancer: Colorectal Cancer, Ambulatory Care and Surgery
Davis MM, Gunn R, Pham R
Key collaborative factors when Medicaid Accountable Care Organizations work with primary care clinics to improve colorectal cancer screening: relationships, data, and quality improvement infrastructure.
This study focused on ways that Medicaid Accountable Care Organizations (ACOs) are implementing interventions with primary care clinics to improve colorectal cancer screening. The researchers conducted a comparative case study of 14 Medicaid ACOs in Oregon and their contracted primary care clinics. They focused on interventions that reduced structural barriers (12 ACOs), delivered provider assessment and feedback (11 ACOs), and provided patient reminders (7 ACOs). There was an unintended consequence of potential exclusion of smaller clinics and metric focus and fatigue.
AHRQ-funded; HS022981.
Citation: Davis MM, Gunn R, Pham R .
Key collaborative factors when Medicaid Accountable Care Organizations work with primary care clinics to improve colorectal cancer screening: relationships, data, and quality improvement infrastructure.
Prev Chronic Dis 2019 Aug 15;16:E107. doi: 10.5888/pcd16.180395..
Keywords: Primary Care: Models of Care, Primary Care, Screening, Colonoscopy, Cancer: Colorectal Cancer, Cancer, Quality Improvement, Quality of Care, Care Coordination, Patient-Centered Healthcare
Bravo RI, Kietzman KG, Toy P
Linking primary care and community organizations to increase colorectal cancer screening rates: the HAPPI project.
This paper describes the Healthy Aging Partnerships in Prevention Initiative (HAPPI) which aims to increase colorectal cancer screening and other preventive services among underserved Latinos and African-Americans in South Los Angeles who are 50 years and older. It uses an evidence-based model (SPARC) to leverage existing resources and has multi-sectoral partnerships among different agencies, community health centers (CHCs), and a university. The authors engaged five CHCs in quality improvement activities and eight non-governmental organizations in networking and programming to increase awareness of these preventive services.
AHRQ-funded; HS010858.
Citation: Bravo RI, Kietzman KG, Toy P .
Linking primary care and community organizations to increase colorectal cancer screening rates: the HAPPI project.
Salud Publica Mex 2019 Jul-Aug;61(4):427-35. doi: 10.21149/9450..
Keywords: Cancer: Colorectal Cancer, Cancer, Screening, Prevention, Primary Care: Models of Care, Primary Care, Elderly, Racial and Ethnic Minorities, Vulnerable Populations, Patient-Centered Healthcare
Huguet N, Angier H, Rdesinski R
Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion.
This study assessed changes in the prevalence of cervical and colorectal cancer screening from before and after the Affordable Care Act in Medicaid expansion and non-expansion states among patients seen in community health centers. Results showed that, despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.
AHRQ-funded; HS024270.
Citation: Huguet N, Angier H, Rdesinski R .
Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion.
Prev Med 2019 Jul;124:91-97. doi: 10.1016/j.ypmed.2019.05.003..
Keywords: Cancer, Cancer: Cervical Cancer, Cancer: Colorectal Cancer, Healthcare Delivery, Healthcare Utilization, Medicaid, Policy, Prevention, Screening
Antunez AG, Kanters AE, Regenbogen SE
Evaluation of access to hospitals most ready to achieve national accreditation for rectal cancer treatment.
This cohort study looked at hospitals’ readiness to be part of the American College of Surgeons National Accreditation Program for Rectal Cancer (NAPRC), and what types of hospitals are most likely to receive NAPRC accreditation. A total of 1315 American College of Surgeons Commission on Cancer-accredited hospitals from the National Cancer Database were sorted into 4 cohorts from 2011 to 2015. They were organized by high versus low volume, adherence to process standards, and patient and hospital characteristics and oncologic outcomes were compared. Among those hospitals, 38 (2.9%) met proposed thresholds for all 5 NAPRC process standards, and 220 (16.7%) met the threshold on 4 standards. Low-adherence hospitals were more likely to serve patients who were older, as well more public insurance recipients, or were black or Hispanic.
ARHQ-funded; HS000053.
Citation: Antunez AG, Kanters AE, Regenbogen SE .
Evaluation of access to hospitals most ready to achieve national accreditation for rectal cancer treatment.
JAMA Surg 2019 Jun;154(6):516-23. doi: 10.1001/jamasurg.2018.5521..
Keywords: Cancer: Colorectal Cancer, Cancer, Hospitals, Quality Improvement, Quality of Care
O'Leary MC, Lich KH, Gu Y
Colorectal cancer screening in newly insured Medicaid members: a review of concurrent federal and state policies.
The goal of this study was to determine the impact of national and state policies enacted to increase access to Medicaid and to promote colorectal cancer (CRC) screening on newly enrolled, age-eligible Oregon Medicaid beneficiaries. 2010 - 2015 Oregon Medicaid claims data was used to conduct a cohort analysis of enrollees who turned 50 and became age-eligible for CRC screening. Individuals newly enrolled in Medicaid in 2013 or 2014 were more likely to initiate CRC screening than those enrolled by 2010, associated with the timing of policies such as Medicaid expansion and federal matching for preventive services. A primary care visit during the calendar year, one or more chronic conditions, and Hispanic ethnicity were also associated with CRC screening initiation.
AHRQ-funded; HS022981.
Citation: O'Leary MC, Lich KH, Gu Y .
Colorectal cancer screening in newly insured Medicaid members: a review of concurrent federal and state policies.
BMC Health Serv Res 2019 May 9;19(1):298. doi: 10.1186/s12913-019-4113-2..
Keywords: Access to Care, Cancer, Cancer: Colorectal Cancer, Medicaid, Policy, Prevention, Screening
Ellis CT, Cole AL, Sanoff HK
Evaluating surveillance patterns after chemoradiation-only compared with conventional management for older patients with rectal cancer.
This study examined surveillance patterns for elderly patients who were treated only with chemoradiation (CR) as opposed to traditional treatment (chemoradiation and protectomy). In the cohort study, a total of 2,482 individuals met the inclusion criteria, with 21% receiving CR-only treatment, and 79% had conventional treatment. In comparison to patients who had traditional treatment, patients with CR-only treatment had far less follow-up during the first 2 years post-treatment. Adherence to guideline-recommended surveillance was poor for all Medicare patients, but especially for CR-only treated patients.
AHRQ-funded; HS000032.
Citation: Ellis CT, Cole AL, Sanoff HK .
Evaluating surveillance patterns after chemoradiation-only compared with conventional management for older patients with rectal cancer.
J Am Coll Surg 2019 May;228(5):782-91.e2. doi: 10.1016/j.jamcollsurg.2019.01.010..
Keywords: Cancer, Cancer: Colorectal Cancer, Care Management, Treatments, Elderly, Patient-Centered Outcomes Research
Chapman WC, Subramanian M, Jayarajan S
First, do no harm: rethinking routine diversion in sphincter-preserving rectal cancer resection.
The authors hypothesized that routine temporary diversion is not associated with decreased rates of leak or reintervention in cancer patients at large undergoing sphincter-sparing procedures. Using HCUP data from the Florida State Inpatient Database, they found no association between diversion and anastomotic leak. However, temporary diversion was associated with increased incidence of nonelective reinterventions, readmissions, and higher costs. They recommended additional study to identify which patients would benefit most from diversion.
AHRQ-funded; HS019455.
Citation: Chapman WC, Subramanian M, Jayarajan S .
First, do no harm: rethinking routine diversion in sphincter-preserving rectal cancer resection.
J Am Coll Surg 2019 Apr;228(4):547-56.e8. doi: 10.1016/j.jamcollsurg.2018.12.012..
Keywords: Healthcare Cost and Utilization Project (HCUP), Cancer: Colorectal Cancer, Cancer, Surgery, Treatments
Mobley LR, Kuo TM, Zhou M
What happened to disparities in CRC screening among FFS Medicare enrollees following Medicare modernization?
This study examined the effects of the change in policy for colorectal screening that was implemented in 2006 for FFS Medicare beneficiaries. This new policy eliminated copayments for colonoscopies or sigmoidoscopies. Disparities in screening by race (Blacks, Asians and Hispanics relative to Whites), and gender (Males relative to Females). The time periods 2001-2005 and 2006-2009 were compared and while there was some improvement in screening rates for minorities and women, the progress was unevenly distributed across the USA.
AHRQ-funded; HS021752.
Citation: Mobley LR, Kuo TM, Zhou M .
What happened to disparities in CRC screening among FFS Medicare enrollees following Medicare modernization?
J Racial Ethn Health Disparities 2019 Apr;6(2):273-91. doi: 10.1007/s40615-018-0522-x..
Keywords: Cancer: Colorectal Cancer, Colonoscopy, Disparities, Medicare, Screening
Lin SC, Regenbogen SE, Hollingsworth JM
Coordination of care around surgery for colon cancer: insights from national patterns of physician encounters with Medicare beneficiaries.
This study researched the coordination of care before and after surgery for colon cancer patients using data from Medicare A and B records. There were quite a number of different combinations of care providers both preoperative and postoperative. Larger urban teaching hospitals had the most combinations in all phases.
AHRQ-funded; HS024525; HS024728.
Citation: Lin SC, Regenbogen SE, Hollingsworth JM .
Coordination of care around surgery for colon cancer: insights from national patterns of physician encounters with Medicare beneficiaries.
J Oncol Pract 2019 Feb;15(2):e110-e21. doi: 10.1200/jop.18.00228..
Keywords: Cancer, Cancer: Colorectal Cancer, Care Coordination, Medicare, Surgery
Abelson JS, Chait A, Shen MJ
Coping strategies among colorectal cancer patients undergoing surgery and the role of the surgeon in mitigating distress: a qualitative study.
This study researched the role that surgeons can play in managing stress in patients undergoing colorectal cancer surgery. Patients were interviewed in-depth using open-ended questions. While patients did not believe surgeons are responsible for helping them cope, they do believe that they can play a role in managing their distress.
AHRQ-funded; HS000066.
Citation: Abelson JS, Chait A, Shen MJ .
Coping strategies among colorectal cancer patients undergoing surgery and the role of the surgeon in mitigating distress: a qualitative study.
Surgery 2019 Feb;165(2):461-68. doi: 10.1016/j.surg.2018.06.005..
Keywords: Cancer: Colorectal Cancer, Clinician-Patient Communication, Provider: Physician, Stress, Surgery
Davis MM, Shafer P, Renfro S
Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing?
This study investigated whether Medicaid expansion due to the Affordable Care Act (ACA) increased the number of patients who tested for colorectal cancer (CRC). Results in Oregon showed that there was an increased in statewide fecal testing mainly in Coordinated Care Organizations (CCOs).
AHRQ-funded; HS022981.
Citation: Davis MM, Shafer P, Renfro S .
Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing?
BMC Health Serv Res 2019 Jan 21;19(1):54. doi: 10.1186/s12913-018-3864-5..
Keywords: Cancer: Colorectal Cancer, Healthcare Utilization, Medicaid, Prevention, Screening
Du XL, Zhang Y
Risks of venous thromboembolism, stroke, heart disease, and myelodysplastic syndrome associated with hematopoietic growth factors in a large population-based cohort of patients with colorectal cancer.
This study sought to determine the relationship between the receipt of colony-stimulating factors (CSFs) with erythropoiesis-stimulating agents (ESAs) and the risk of developing venous thromboembolism (VTE), stroke, heart disease, and myelodysplastic syndrome (MDS) in patients with colorectal cancer. It found that the use of ESAs was significantly associated with a substantially increased risk of MDS in patients with colorectal cancer.
AHRQ-funded; HS018956.
Citation: Du XL, Zhang Y .
Risks of venous thromboembolism, stroke, heart disease, and myelodysplastic syndrome associated with hematopoietic growth factors in a large population-based cohort of patients with colorectal cancer.
Clin Colorectal Cancer 2015 Dec;14(4):e21-31. doi: 10.1016/j.clcc.2015.05.007.
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Keywords: Adverse Drug Events (ADE), Cancer: Colorectal Cancer, Cardiovascular Conditions, Patient-Centered Outcomes Research, Risk
El-Shami K, Oeffinger KC, Erb NL
American Cancer Society colorectal cancer survivorship care guidelines.
Communication and coordination of care between the treating oncologist and the primary care clinician is critical to effectively and efficiently manage the long-term care of colorectal cancer (CRC) survivors. The guidelines in this article are intended to assist primary care clinicians in delivering risk-based health care for CRC survivors who have completed active therapy.
AHRQ-funded; HS020937.
Citation: El-Shami K, Oeffinger KC, Erb NL .
American Cancer Society colorectal cancer survivorship care guidelines.
CA Cancer J Clin 2015 Nov-Dec;65(6):428-55. doi: 10.3322/caac.21286.
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Keywords: Cancer, Cancer: Colorectal Cancer, Care Coordination, Guidelines, Primary Care
Murphy DR, Wu L, Thomas EJ
Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial.
The researchers tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer. They found that electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up.
AHRQ-funded; HS017820.
Citation: Murphy DR, Wu L, Thomas EJ .
Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial.
J Clin Oncol 2015 Nov 1;33(31):3560-7. doi: 10.1200/jco.2015.61.1301..
Keywords: Cancer: Colorectal Cancer, Cancer: Lung Cancer, Cancer: Prostate Cancer, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT)
Liu H, Mattke S, Predmore ZS
Medicare coverage of anesthesia services during screening colonoscopies for patients at low risk of sedation-related complications.
The authors examined the costs and potential benefit of the Medicare rule change that waived patient cost sharing for anesthesia services during screening colonoscopies. Their results cast doubt on the value associated with Medicare coverage of anesthesia services during screening colonoscopies for patients at low risk of sedation-related complications. They recommended that payers create payment bundles for endoscopy procedures that include anesthesia services in a fixed fee.
AHRQ-funded; HS000029.
Citation: Liu H, Mattke S, Predmore ZS .
Medicare coverage of anesthesia services during screening colonoscopies for patients at low risk of sedation-related complications.
JAMA Intern Med 2015 Nov;175(11):1848-50. doi: 10.1001/jamainternmed.2015.4585.
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Keywords: Adverse Drug Events (ADE), Cancer: Colorectal Cancer, Colonoscopy, Medicare, Medication
Kahn B, Freeland Z, Gopal P
Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system.
The aim of this study was to quantify and identify predictors for guideline-concordant surveillance recommendations after adenoma polypectomy. It found that underuse recommendations were more likely in patients with C3 adenomas; overuse recommendations were more likely in patients with high-grade dysplasia or fair prep quality and less likely in those with piecemeal resection, C3 adenomas, age>65, or Hispanic ethnicity.
AHRQ-funded; HS022418.
Citation: Kahn B, Freeland Z, Gopal P .
Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system.
Cancer Causes Control 2015 Nov;26(11):1653-60. doi: 10.1007/s10552-015-0661-x..
Keywords: Cancer: Colorectal Cancer, Colonoscopy, Guidelines, Patient Adherence/Compliance, Patient-Centered Outcomes Research
Baker DW, Brown T, Goldman SN
Two-year follow-up of the effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers.
After an earlier outreach intervention achieved 82 percent annual adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT), this study assessed adherence to FOBT after a second outreach. It found that a total of 88.7 percent of patients completed a fecal immunochemical test within 6 months of their second outreach.
AHRQ-funded; HS021141.
Citation: Baker DW, Brown T, Goldman SN .
Two-year follow-up of the effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers.
Cancer Causes Control 2015 Nov;26(11):1685-90. doi: 10.1007/s10552-015-0650-0..
Keywords: Cancer, Cancer: Colorectal Cancer, Patient Adherence/Compliance, Prevention, Screening
Abdelsattar ZM, Birkmeyer JD, Wong SL
Variation in Medicare payments for colorectal cancer surgery.
The researchers assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variation in payment for colorectal cancer surgery (CRC). They concluded that Medicare spending in the first year after CRC surgery varies across hospitals even after case-mix adjustment and price standardization. Variation is largely driven by postacute care and not the index surgical hospitalization.
AHRQ-funded; HS020937; HS000053.
Citation: Abdelsattar ZM, Birkmeyer JD, Wong SL .
Variation in Medicare payments for colorectal cancer surgery.
J Oncol Pract 2015 Sep;11(5):391-5. doi: 10.1200/jop.2015.004036.
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Keywords: Cancer, Cancer: Colorectal Cancer, Payment, Medicare, Surgery
Brenner AT, Ko LK, Janz N
Race/ethnicity and primary language: health beliefs about colorectal cancer screening in a diverse, low-income population.
The purpose of this paper was to explore whether health belief model (HBM) constructs pertaining to colorectal cancer (CRC) screening differ by race/ethnicity and primary language. Understanding how different populations think about CRC screening may be critical in promoting screening in diverse populations.
AHRQ-funded; HS013853.
Citation: Brenner AT, Ko LK, Janz N .
Race/ethnicity and primary language: health beliefs about colorectal cancer screening in a diverse, low-income population.
J Health Care Poor Underserved 2015 Aug;26(3):824-38. doi: 10.1353/hpu.2015.0075.
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Keywords: Cancer: Colorectal Cancer, Cultural Competence, Low-Income, Racial and Ethnic Minorities, Screening
Kenzik K, Pisu M, Johns SA
Unresolved pain interference among colorectal cancer survivors: Implications for patient care and outcomes.
This study describes pain interference (PI) prevalence across the cancer continuum; 2) identifies demographic and clinical factors associated with PI and changes in PI; and 3) examines PI’s relationship with survivors’ job changes. It concluded that almost half of survivors with PI during the initial phase of care had continued PI into posttreatment. Comorbidities, especially cardiovascular and pulmonary conditions, contributed to continued PI.
AHRQ-funded; HS013852.
Citation: Kenzik K, Pisu M, Johns SA .
Unresolved pain interference among colorectal cancer survivors: Implications for patient care and outcomes.
Pain Med 2015 Jul;16(7):1410-25. doi: 10.1111/pme.12727..
Keywords: Cancer, Cancer: Colorectal Cancer, Quality of Life, Pain, Patient-Centered Outcomes Research
Gallego CJ, Shirts BH, Bennette CS
Next-generation sequencing panels for the diagnosis of colorectal cancer and polyposis syndromes: a cost-effectiveness analysis.
The researchers evaluated the cost effectiveness of next-generation sequencing (NGS) panels for the diagnosis of colorectal cancer and polyposis (CRCP) syndromes in patients referred to cancer genetics clinics. They concluded that the use of an NGS panel that includes genes associated with highly penetrant CRCP syndromes in addition to Lynch syndrome genes as a first-line test is likely to provide meaningful clinical benefits in a cost-effective manner.
AHRQ-funded; HS021686.
Citation: Gallego CJ, Shirts BH, Bennette CS .
Next-generation sequencing panels for the diagnosis of colorectal cancer and polyposis syndromes: a cost-effectiveness analysis.
J Clin Oncol 2015 Jun 20;33(18):2084-91. doi: 10.1200/jco.2014.59.3665..
Keywords: Cancer, Cancer: Colorectal Cancer, Shared Decision Making, Diagnostic Safety and Quality, Genetics, Healthcare Costs, Screening