Abstract
BACKGROUND: Given the Centers for Medicare and Medicaid Services' coverage of screening CT colonography (CTC) beginning in January 2025, we evaluated the cost-effectiveness of CTC for colorectal cancer (CRC) screening by race (Black and White) and gender, considering real-world screening adherence. METHODS: A microsimulation model compared CRC screening strategies in average-risk adults by race and gender, incorporating 2010-2019 U.S. data on disease progression and real-world screening adherence for colonoscopy and fecal immunochemical test (FIT). Five strategies were compared: (1) status quo (choice between colonoscopy and FIT); (2) CTC every 5 years; (3) colonoscopy every 10 years; (4) annual FIT; and (5) multitarget stool DNA test every 3 years, plus no screening. Lifetime costs, quality-adjusted life years gained (QALYG), and incremental cost-effectiveness ratios were projected. A willingness-to-pay threshold of $100,000/QALYG was used. RESULTS: Under the status quo, Black adults showed higher CRC cases and greater utilization for FIT over colonoscopy than White adults. Compared to the status quo, the CTC strategy yielded more QALYG and fewer CRC cases among Black adults, but fewer QALYG and more CRC cases among White adults. Both status quo and CTC strategies outperformed other strategies across races. The CTC strategy was the dominant strategy for Black adults. For White adults, the status quo was cost-effective with incremental cost-effectiveness ratios of $34,998-$73,428/QALYG, while the CTC strategy was cost saving compared to no screening. CONCLUSIONS: CTC could be cost-effective for CRC screening in Black adults under real-world screening adherence, supporting Medicare coverage to address specific population needs and structural barriers to screening.