Hopes for adoption of CT colonography dim on poor cost-effectiveness

August 6, 2010

To paraphrase Harry Truman, what virtual colonoscopy needs is a one-handed analyst. This was made clear earlier this week in the share price activity of iCAD , which leaped about 18% on news that the FDA had cleared the company’s VeraLook software for interpreting virtual colonoscopy exams. The next day the stock gave back about as much ground as it had gained.

To paraphrase Harry Truman, what CT colonography needs is a one-handed analyst. This was made clear earlier this week in the share price activity of iCAD , which leaped about 18% on news that the FDA had cleared the company’s VeraLook software for interpreting virtual colonoscopy exams. The next day the stock gave back about as much ground as it had gained.

On the one hand, virtual colonoscopy holds enormous promise-and potential for entrepreneurs-as a cancer screening tool. This CT-based version, which depends on software-based interpretation, is decidedly unintimidating compared with its optically based twin. This raises the prospect that the millions of people who have put off being screened for colon cancer might step forward if a virtual solution were widely available.

On the other hand, colonography can be hard to find. Despite the widespread availability of CT scanners, very few are used to search for precancerous polyps. The problem is reimbursement. The Centers for Medicare and Medicaid Services does not reimburse for this exam. Neither do a lot of third-party payers. Prospects for the future dimmed on recent findings at the Institute for Technology Assessment at Massachusetts General Hospital. Fortunately, the findings were cushioned by a Trumanism.

The MGH researchers concluded that virtual colonoscopy, also called CT colonography (CTC), is not cost-effective if reimbursed at the same rate as colonoscopy. In a study published online July 27 in The Journal of the National Cancer Institute, researchers considered 15 screening strategies for a previously unscreened population of Medicare beneficiaries, starting at age 65. They found that if CTC were reimbursed at $488, which is approximately the same rate as colonoscopy, lifetime costs associated with CTC screening exceed those of colonoscopy.

“If CTC screening is reimbursed at roughly the same rate as colonoscopy, the cost, relative to the benefit derived and to the availability and costs of other colorectal screening tests, is too high for it to be a cost-effective screening strategy,” they wrote, noting that reimbursement would have to range between $108 and $205 to be cost-effective.

But… they also found that CTC would be cost-effective at a rate comparable to that of optical colonoscopy if its availability enticed 25% of otherwise unscreened individuals to come in for screening with CTC. (In a kind of third-hand observation, the researchers noted that there is no reason to believe more individuals would be screened for colon cancer if offered CTC.)

So it is that virtual colonography languishes, trapped in a kind of medicoeconomic no man’s land, batted back and forth from one hand to another. Meanwhile, other technologies continue to evolve, raising the very real possibility that, unless CTC takes hold soon, it may never do so.

In an editorial that accompanied the MGH paper, Dr. Russell Harris, a professor of medicine at the University of North Carolina, asked: “Wouldn’t it be interesting if we ended up, a few years from now, with neither CT colonography nor optical colonoscopy as the primary screening test, but rather an improved fecal test as our ‘gold standard’?”