Skip to main content
    • Aa
    • Aa

Can calcium chemoprevention of adenoma recurrence substitute or serve as an adjunct for colonoscopic surveillance?

  • Aasma Shaukat (a1), Murtaza Parekh (a2), Joseph Lipscomb (a3) and Uri Ladabaum (a2)

Objectives: The aim of this study was to examine the potential cost-effectiveness of calcium chemoprevention post-polypectomy as a substitute or adjunct for surveillance.

Methods: We constructed a Markov model of post-polypectomy adenoma recurrence and colorectal cancer (CRC) development, calibrated to data from prospective chemoprevention trials of fiber, calcium, antioxidants, and aspirin. We modeled four scenarios for 50-year-old patients immediately after polypectomy: (i) natural history with no further intervention; (ii) elemental calcium 1,200 mg/day from age 50–80; (iii) surveillance colonoscopy from age 50–80 every 5 years, or 3 years for large adenoma; (iv) calcium + surveillance. Patients were followed up until age 100 or death.

Results: Calcium was cost-effective compared to natural history ($49,900/life-year gained). However, surveillance was significantly more effective than calcium (18.729 versus 18.654 life-years/patient; 76 percent versus 14 percent reduction in CRC incidence) at an incremental cost of $15,900/life-year gained. Calcium + surveillance yielded a very small benefit (0.0003 incremental life-years/patient) compared with surveillance alone, at a substantial incremental cost of $3,090,000/life-year gained.

Conclusion: Post-polypectomy calcium chemoprevention is unlikely to be a reasonable substitute for surveillance. It may be cost-effective in patients unwilling or unable to undergo surveillance.

Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

1. DS Alberts , ME Martinez , DJ Roe , Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas. Phoenix Colon Cancer Prevention Physicians’ Network. N Engl J Med. 2000;342:11561162.

2. WF Anderson , A Umar , JL Viner , ET Hawk . The role of cyclooxygenase inhibitors in cancer prevention. Curr Pharm Des. 2002;8:10351062.

3. MR Arguedas , GR Heudebert , CM Wilcox . Surveillance colonoscopy or chemoprevention with COX-2 inhibitors in average-risk post-polypectomy patients: A decision analysis. Aliment Pharmacol Ther. 2001;15:631638.

4. JA Baron , M Beach , JS Mandel , Calcium supplements for the prevention of colorectal adenomas. Calcium Polyp Prevention Study Group [see comment]. N Engl J Med. 1999;340:101107.

5. JA Baron , B F Cole , RS Sandler , A randomized trial of aspirin to prevent colorectal adenomas [see comment]. N Engl J Med. 2003;348:891899.

7. JH Bond . Polyp guideline: Diagnosis, treatment, and surveillance for patients with colorectal polyps. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 2000;95:30533063.

8. C Bonithon-Kopp , F Piard , C Fenger , Colorectal adenoma characteristics as predictors of recurrence. Dis Colon Rectum. 2004;47:323333.

9. ML Brown , GF Riley , AL Potosky , RD Etzioni . Obtaining long-term disease specific costs of care: Application to Medicare enrollees diagnosed with colorectal cancer. Med Care. 1999;37:12491259.

11. S Cotton , L Sharp , J Little . The adenoma-carcinoma sequence and prospects for the prevention of colorectal neoplasia. Crit Rev Oncog. 1996;7:293342.

12. DM Eddy . Screening for colorectal cancer. Ann Intern Med. 1990;113:373384.

13. DM Eddy , FW Nugent , JF Eddy , Screening for colorectal cancer in a high-risk population. Results of a mathematical model. Gastroenterology. 1987;92:682692.

15. AL Frazier , GA Colditz , CS Fuchs , KM Kuntz . Cost-effectiveness of screening for colorectal cancer in the general population. JAMA. 2000;284:19541961.

16. E Giovannucci . Modifiable risk factors for colon cancer. Gastroenterol Clin North Am. 2002;31:925943.

17. MV Grau , JA Baron , EL Barry , Interaction of calcium supplementation and nonsteroidal anti-inflammatory drugs and the risk of colorectal adenomas. Cancer Epidemiol Biomarkers Prev. 2005;14:2353–1258.

18. ER Greenberg , JA Baron , TD Tosteson , A clinical trial of antioxidant vitamins to prevent colorectal adenoma. Polyp Prevention Study Group. N Engl J Med. 1994;331:141147.

19. RT Greenlee , T Murray , S Bolden , PA Wingo . Cancer statistics, 2000. CA Cancer J Clin. 2000;50:733.

20. ET Hawk , PJ Limburg , JL Viner . Epidemiology and prevention of colorectal cancer. Surg Clin North Am. 2002;82:905941.

21. RP Heaney , MS Dowell , J Bierman , CA Hale , A Bendich . Absorbability and cost effectiveness in calcium supplementation. J Am Coll Nutr. 2001;20:239246.

23. JL Keller , A Lanou , ND Barnard . The consumer cost of calcium from food and supplements. J Am Diet Assoc. 2002;102:16691671.

24. RK Khandker , JD Dulski , JB Kilpatrick , A decision model and cost-effectiveness analysis of colorectal cancer screening and surveillance guidelines for average-risk adults. Int J Technol Assess Health Care. 2000;16:799810.

25. U Ladabaum , CL Chopra , G Huang , Aspirin as an adjunct to screening for prevention of sporadic colorectal cancer. A cost-effectiveness analysis. Ann Intern Med. 2001;135:769781.

26. U Ladabaum , JM Scheiman , AM Fendrick . Potential effect of cyclooxygenase-2-specific inhibitors on the prevention of colorectal cancer: A cost-effectiveness analysis. Am J Med. 2003;114:546554.

27. U Ladabaum , K Song . Projected national impact of colorectal cancer screening on clinical and economic outcomes and health services demand [see comment]. Gastroenterology. 2005;129:11511162.

28. U Ladabaum , K Song , AM Fendrick . Colorectal neoplasia screening with virtual colonoscopy: When, at what cost, and with what national impact? Clin Gastroenterol Hepatol. 2004;2:554563.

29. SA Lamprecht , M Lipkin . Chemoprevention of colon cancer by calcium, vitamin D and folate: Molecular mechanisms. Nat Rev Cancer. 2003;3:601614.

30. DI Levenson , RS Bockman . A review of calcium preparations [erratum appears in Nutr Rev. 1994;52:364]. Nutr Rev. 1994;52:221232.

32. M Lipkin , B Reddy , H Newmark , SA Lamprecht . Dietary factors in human colorectal cancer. Annu Rev Nutr. 1999;19:545586.

33. ME Martinez , R Sampliner , JR Marshall , Adenoma characteristics as risk factors for recurrence of advanced adenomas. Gastroenterology. 2001;120:10771083.

35. BC Morson . The evolution of colorectal carcinoma. Clin Radiol. 1984;35:425431.

37. AI Neugut , JS Jacobson , H Ahsan , Incidence and recurrence rates of colorectal adenomas: A prospective study. Gastroenterology. 1995;108:402408.

38. KC Noshirwani , RU van Stolk , LA Rybicki , GJ Beck . Adenoma size and number are predictive of adenoma recurrence: Implications for surveillance colonoscopy. Gastrointest Endosc. 2000;51 (pt 1):433437.

39. DM Parkin , F Bray , J Ferlay , P Pisani . Estimating the world cancer burden: Globocan 2000. Int J Cancer. 2001;94:153156.

40. DM Parkin , P Pisani , J Ferlay . Global cancer statistics. CA Cancer J Clin. 1999;49:3364.

41. BC Pence . Role of calcium in colon cancer prevention: Experimental and clinical studies. Mutat Res. 1993;290:8795.

42. PJ Pickhardt , JR Choi , I Hwang , Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349:21912200.

45. DK Rex , CS Cutler , GT Lemmel , Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology. 1997;112:2428.

47. DJ Robertson , ER Greenberg , M Beach , Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology. 2005;129:3441.

48. AJ Rosner , DT Grima , GW Torrance , Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis. Pharmacoeconomics. 1998;14:559573.

49. RS Sandler , S Halabi , JA Baron , A randomized trial of aspirin to prevent colorectal adenomas in patients with previous colorectal cancer [see comment][erratum appears in N Engl J Med. 2003;348:1939]. N Engl J Med. 2003;348;883890.

50. A Schatzkin , E Lanza , D Corle , Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Polyp Prevention Trial Study Group. N Engl J Med. 2000;342:11491155.

51. RE Schoen . Surveillance after positive and negative colonoscopy examinations: Issues, yields, and use. Am J Gastroenterol. 2003;98:12371246.

52. A Shaukat , N Scouras , HJ Schunemann . Role of supplemental calcium in the recurrence of colorectal adenomas: A metaanalysis of randomized controlled trials [see comment]. Am J Gastroenterol. 2005;100:390394.

54. K Song , AM Fendrick , U Ladabaum . Fecal DNA testing compared with conventional colorectal cancer screening methods: A decision analysis. Gastroenterology. 2004;126:12701279.

55. A Sonnenberg , F Delco , JM Inadomi . Cost-effectiveness of colonoscopy in screening for colorectal cancer. Ann Intern Med. 2000;133:573584.

56. S Suleiman , DK Rex , A Sonnenberg . Chemoprevention of colorectal cancer by aspirin: A cost-effectiveness analysis [see comment]. Gastroenterology. 2002;122:7884.

57. SH Taplin , W Barlow , N Urban , Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care. J Natl Cancer Inst. 1995;87 (6):417426.

58. P Terry , JA Baron , L Bergkvist , L Holmberg , A Wolk . Dietary calcium and vitamin D intake and risk of colorectal cancer: A prospective cohort study in women. Nutr Cancer. 2002;43:3946.

59. S Vijan , EW Hwang , TP Hofer , RA Hayward . Which colon cancer screening test? A comparison of costs, effectiveness, and compliance. Am J Med. 2001;111:593601.

60. J Wactawski-Wende , JM Kotchen , GL Anderson , Calcium plus vitamin D supplementation and the risk of colorectal cancer [see comment][erratum appears in N Engl J Med. 2006;354:1102]. N Engl J Med. 2006;354:684696.

62. M Wegener , G Borsch , G Schmidt . Colorectal adenomas. Distribution, incidence of malignant transformation, and rate of recurrence. Dis Colon Rectum. 1986;29:383387.

63. SJ Winawer , RH Fletcher , L Miller , Colorectal cancer screening: Clinical guidelines and rationale. Gastroenterology. 1997;112:594642.

64. S Winawer , R Fletcher , D Rex , Colorectal cancer screening and surveillance: Clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003;124:544560.

65. SJ Winawer , AG Zauber , MN Ho , Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329:19771981.

66. SJ Winawer , AG Zauber , MJ O'Brien , Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med. 1993;328:901906.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

International Journal of Technology Assessment in Health Care
  • ISSN: 0266-4623
  • EISSN: 1471-6348
  • URL: /core/journals/international-journal-of-technology-assessment-in-health-care
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary Materials

Shaukat supplementary material
Supplementary figure 1

 Unknown (147 KB)
147 KB
Supplementary Materials

Shaukat supplementary material

 Word (37 KB)
37 KB


Full text views

Total number of HTML views: 2
Total number of PDF views: 8 *
Loading metrics...

Abstract views

Total abstract views: 77 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 24th September 2017. This data will be updated every 24 hours.