前言: 大腸癌往往佔已發展國家主要癌症死因的第二位，僅次於肺癌。為了要讓潛在的大腸癌提早發現與治療，因此推動糞便潛血篩檢計畫，以早期發現潛在的大腸癌個案，及時治療減少死亡。過去研究發現診斷期別越早，終身餘命越長、預期壽命損失年數越短且治療成本也越少；但是我國目前仍缺少驗證大腸癌糞便潛血篩檢與確診健康效應的研究。故本研究利用大腸癌糞便潛血篩檢檔、大腸癌確診檔取得50-64歲族群篩檢情形；探討該族群於2010-2012結腸腺癌確診情形，並估算大腸癌篩檢之有無，與篩檢後民眾被診為結腸腺癌，其預期壽命損失年數及健保花費；以及在不同糞便潛血篩檢率與陽性個案追蹤完成率組合下，族群的預期壽命損失年數與終身健保花費等效應。
材料與方法: 使用2010年戶籍檔內50-69現住人口族群，比對2010年大腸癌糞便潛血篩檢檔、2010年大腸癌確診檔、2010-2012年癌症登記檔長表；追蹤在2010年糞便潛血篩檢有無與不同篩檢完成度族群，在2010-2012年的結腸腺癌發生率與大腸癌癌症期別分布，並運用Po-Chuan Chen等人(2015)計算不同結腸腺癌癌症期別的預期壽命損失年數與終身健保花費，以評估糞便篩檢率與不同篩檢完成度族群的預期壽命損失年數與終身健保花費。進一步分析則依照不同篩檢完成度族群之結腸腺癌期別分布，乘上各期別的預期壽命損失年數與終身健保花費，算出提升糞便潛血篩檢率與提升糞便潛血陽性個案追蹤完成率時，能夠減少的預期壽命損失年數與健保花費。
結果:本研究發現2010-2011年間未進行糞便潛血篩檢族群，在2010-2012年間結腸腺癌發生率高於已篩檢族群的結腸腺癌發生率，且同時發現未進行糞便潛血篩檢族群的結腸腺癌癌症期別分布在第三期與第四期的情形也高於已篩檢族群。在已篩檢族群中，篩檢結果為陽性個案但沒有完成確診的族群，結腸腺癌發生率高於篩檢為陰性族群與篩檢結果為陽性但有去確診族群，且同時發現篩檢結果為陽性但沒去確診族群，結腸腺癌期別分布在第三期和第四期的情形也高於篩檢為陰性族群與篩檢結果為陽性但有去確診族群。結合Po-Chuan Chen等人(2015)計算篩檢有無與不同篩檢完成度狀態的預期壽命損失與終身健保花費，發現在2010-2012年結腸腺癌族群中，已進行糞便潛血篩檢族群的預期壽命損失，50-54歲男性、55-59歲男性、60-64歲男性、65-69歲男性分別為預期壽命損失年數為2.8809、3.5887、3.3518、1.6024年，終身健保花費為US $9997±6785、US $11316±7660、US $11610±8176、US $8567±7275；50-54歲女性、55-59歲女性、60-64歲女性、65-69歲女性的的預期壽命損失年數為5.7436、5.1925、4.2335、2.4363年，終身花費為US $11863±10735、US $10701±10761、US $11213±9235、US $10071±6004。
若是未進行糞便潛血篩檢族群的預期壽命損失，50-54歲男性、55-59歲男性、60-64歲男性、65-69歲男性的預期壽命損失年數為4.9418、4.8003、4.8233、2.3490年，終身健保花費為US $13224±4845、US $13265±5771、US $13588 ±5515、US $10068±5340；50-54歲女性、55-59歲女性、60-64歲女性、65-69歲女性的的預期壽命損失年數分別為7.7282、8.3632、7.4744、3.1742年，終身健保花費為US $13503±7350、US $13523±6692、US $13386±5860、US $10430±4503。上述結果可看出未進行糞便潛血篩檢族群的損失餘命和終身健保花費高於已進行糞便潛血篩檢族群。
在篩檢後續確診結果中，2010-2012年發生結腸腺癌族群中，篩檢結果為陽性但後續未確診族群的預期壽命損失，50-54歲男性、55-59歲男性、60-64歲男性、65-69歲男性的預期壽命損失年數為1.8943、5.1855、3.8014、1.7333年，終身健保花費為US $9594±6910、US $12755±5809、US $12345±7226、US $8223±6046；50-54歲女性、55-59歲女性、60-64歲女性、65-69歲女性的的預期壽命損失年數分別為7.4971、6.3488、4.4680、2.5340年，終身健保花費為US $13784 ±7012、US $11725±9828、US $11044±6407、US $11131±4763。
若是篩檢結果為陽性且完成確診族群，50-54歲男性、55-59歲男性、60-64歲男性、65-69歲男性的預期壽命損失年數為3.6156、3.7075、4.0250、1.6431年，終身健保花費為US $10859±5309、US $11200±8701、US $12600±7729、US $8223±6046；50-54歲女性、55-59歲女性、60-64歲女性、65-69歲女性的的預期壽命損失年數分別為5.3475、3.1844、4.0511、2.4550年，終身健保花費為US $11115±10973、US $8811±12844、US $10220±9484、US $10052±6050。
篩檢結果為陰性族群，50-54歲男性、55-59歲男性、60-64歲男性、65-69歲男性的預期壽命損失年數為2.9659、3.0174、2.9630、1.5459年，終身花費為US $9737±7498、US $10873±7848、US $11021±8593、US $8569±7703；50-54歲女性、55-59歲女性、60-64歲女性、65-69歲女性的的預期壽命損失年數分別為5.3359、5.5625、4.2433、2.4121年，終身健保花費為US $11525±11809、US $11065±10313、US $11540±9696、US $9879 ±6222。因此也看看出在已進行糞便潛血篩檢族群中，篩檢結果為陽性但不去做確診族群，其預期壽命損失與終身健保花費都高於篩檢結果為陽性且完成確診族群、篩檢結果為陰性族群。
在提升糞便潛血篩檢率與糞便潛血陽性個案追蹤率中，也發現族群會因為糞便潛血篩檢率與糞便潛血陽性個案追蹤率的提升，預期壽命損失與終身健保花費也會隨之下降。
結論:在2010年的可篩檢族群之中，糞便潛血篩檢有無與不同篩檢完成度會影響後續發生結腸腺癌時的預期壽命損失與終身健保花費，且發現未進行糞便潛血篩檢族群的預期壽命損失和終身健保花費高於已進行糞便潛血篩檢族群，在已進行糞便潛血篩檢族群中，篩檢為陽性但未完成確診族群的預期壽命損失和終身健保花費也高於篩檢為陽性且完成確診族群、篩檢為陰性族群。且隨著糞便潛血篩檢率與糞便潛血陽性個案追蹤完成率的提升的提升，預期壽命損失與終身健保花費也會隨之下降。

Background
Colorectal cancer is the second leading cause of cancer-related deaths in the developed country. Colorectal cancer screening is effective not only for early diagnosis but also early treatment. Because of the benefit of colorectal cancer screening, the plan of immunoassay fecal occult blood test in Taiwan has been starting since 2004. The previous studies showed that treating colon adenocarcinoma at earlier stage can save more life-years and healthcare costs. However, we lacked the benefit of colorectal cancer screening in Taiwan.
The aim of this study is to use the data of colorectal cancer screening between 2010-2012 to investigate the history of colorectal cancer screening from 2010 to 2012 for aged 50-69 populations. Then, we investigated different colorectal cancer screening groups of the history of colorectal cancer in 2010-2012, and to estimate Expected-Years-of-Life-Lost(EYLL) and healthcare cost by different colorectal cancer screening group who diagnosis with colorectal cancer. Finally, we estimated the health benefit of colorectal cancer screening by different combination of colorectal cancer screening rate and the follow-up completion rate.

Method and Material
The dataset including the registry for household data in 2010, colorectal cancer screening data, Taiwan Cancer Registry, Ambulatory Care Expenditures by Visits, Inpatient Expenditures by Admissions, Details of Ambulatory Care Orders and Details of Inpatient Orders, the study population included the individuals who were enrolled in the registry for household data among 50-69 years old in 2010.
The study population would be classification in four groups: have not completed iFOBT since 2010-2011, iFOBT result is negative in 2010, iFOBT result is positive and have finished follow-up, iFOBT result is positive and haven’t finished follow-up. We followed up these groups from 2010 to 2012 by Taiwan Cancer Registry, using the International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3) coding, the following site codes were included: c180, c182-187, and c199 to identify all colorectal adenocarcinomas with primary sites. We excluded the individuals who were enrolled in National Register of Deaths before 2010/1/1.
To analyze Expected-Years-of-Life-Lost(EYLL) and healthcare cost, the study will quote the Po-Chuan Chen’s study (2015) which estimated the Expected-Years-of-Life-Lost(EYLL) and healthcare cost of colorectal adenocarcinoma by different stages. Thus, we estimated the benefit of colorectal cancer screening by calculating different group which colorectal cancer screening is completed or not. However, in Po-Chuan Chen’s study (2015) haven’t estimated the healthcare cost for the colorectal adenocarcinoma of stage 0 and stage 1. We obtain the cost of colorectal adenocarcinoma of stage 0 and stage 1 before diagnosis for 1 years.
Finally, we estimated the health benefit of colorectal cancer screening by different combination of colorectal cancer screening rate and the follow-up completion rate. We fixed the percent of the colorectal adenocarcinoma’s stage at different colorectal cancer screening group. Adjusted the colorectal cancer screening rate in 0%、20%、40%、60%、80%、100% and the follow-up completion rate in 60%、80%、100%. Comparison the different combination of the colorectal cancer screening rate and the follow-up completion rate by calculating the Expected-Years-of-Life-Lost(EYLL) and healthcare cost.

Result
The result demonstrated the colorectal adenocarcinoma incidence of a group which have not completed iFOBT since 2010-2011 is higher than a group with having completed iFOBT since 2010. The percent of the stage 3 colorectal adenocarcinoma and stage 4 colorectal adenocarcinoma in a group which have not completed iFOBT since 2010-2011 is also higher than a group with having completed iFOBT since 2010. Focus on a group whom iFOBT result is positive and haven’t finished follow-up, the colorectal adenocarcinoma incidence is higher than a group whom iFOBT result is negative in 2010 and iFOBT result is positive and have finished follow-up, and the percent of the stage 3 colorectal adenocarcinoma and stage 4 colorectal adenocarcinoma were still higher than a group whom iFOBT result is negative in 2010 and iFOBT result is positive and have finished follow-up.
Combined Po-Chuan Chen’s study to estimate EYLL and healthcare cost, we found that the EYLL of males who have complete iFOBT with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were 2.8809, 3.5887, 3.3518, 1.6024 years; The healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $9997±6785, US $11316±7660, US $11610±8176, US $8567±7275. By the EYLL of females, who have complete iFOBT with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were 5.7436, 5.1925, 4.2335,2.4363; The healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $11863±10735, US $10701±10761, US $11213±9235, US $10071±6004.
If we concern a group which has not completed iFOBT since 2010-2011,the EYLL of males in aged 50-54, 55-59, 60-64 and 65-69 were 4.9418, 4.8003, 4.8233, 2.3490; The healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $13224±4845, US $13265±5771, US $13588 ±5515, US $10068±5340. The EYLL of females with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were 7.7282, 8.3632, 7.4744, 3.1742 years; the healthcare costs were US $13503±7350, US $13523±6692, US $13386±5860, US $10430±4503. In the above result, we found a group with not completing iFOBT, the EYLL and the healthcare cost were higher than a group with completing iFOBT.
In a group with completing iFOBT, we demonstrate that the EYLL of males whom iFOBT results were positive and have not following up with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were 1.8943, 5.1855, 3.8014, 1.7333 years; the healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $9594±6910, US $12755±5809, US $12345±7226, US $8223±6046. The EYLL of females with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were7.4971, 6.3488, 4.4680, 2.5340, the healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $13784 ±7012, US $11725±9828, US $11044±6407, US $11131±4763.
If we focus on a group whom iFOBT results were positive and having follow-up,we found that the EYLL of males with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were 3.6156, 3.7075. 4.0250, 1.6431 years; the healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $10859±5309, US $11200±8701, US $12600±7729, US $8223±6046. The EYLL of females with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were 5.3475, 3.1844, 4.0511, 2.4550 years; the healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $11115±10973, US $8811±12844, US $10220±9484, US $10052±6050.
Concerned a group whom iFOBT result were negative, the EYLL of males with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were 2.9659, 3.0174, 2.9630, 1.5459years; the healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $9737±7498, US $10873±7848, US $11021±8593, US $8569±7703. The EYLL of females with colorectal adenocarcinoma in aged 50-54, 55-59, 60-64 and 65-69 were 5.3359, 5.5625, 4.2433, 2.4121 years; the healthcare costs in aged 50-54, 55-59, 60-64 and 65-69 were US $11525±11809, US $11065±10313, US $11540±9696, US $9879 ±6222. In the above result, we still found that a group whom iFOBT result were positive and had not completed follow-up, the EYLL and the healthcare cost were higher than a group whom iFOBT result were positive with completing follow-up and a group whom iFOBT result were negative.
Combined different colorectal cancer screening rate and the follow-up completion rate, we found that EYLL decreases as the colorectal cancer screening and follow-up completion rate increases. We also found that healthcare cost decreases as the colorectal cancer screening and follow-up completion rate increases.

Conclusion
In the population who aged 50-69, the different of completing iFOBT or not and the different of completing follow-up or not will effect EYLL and healthcare cost after colorectal adenocarcinoma happened. In this study, we found a group with not completing iFOBT, the EYLL and the healthcare cost were higher than a group with completing iFOBT. In a group with completing iFOBT, we still found that a group whom iFOBT result were positive and had not completed follow-up, the EYLL and the healthcare cost were higher than a group whom iFOBT result were positive with completing follow-up and a group whom iFOBT result were negative. Combined different colorectal cancer screening rate and the follow-up completion rate, we also found that healthcare cost and the EYLL decreases as the colorectal cancer screening and follow-up completion rate increases.

Ananthakrishnan, A. N., Schellhase, K. G., Sparapani, R. A., Laud, P. W., & Neuner, J. M. (2007). Disparities in colon cancer screening in the Medicare population. Archives of Internal Medicine, 167(3), 258-264.
Authoritative information and statistics to promote better health and wellbeing. National Bowel Cancer Screening Program: monitoring report 2013–14. Retrieved June 1, 2016, from http://www.aihw.gov.au/publication-detail/? id=60129551421.
Burnett-Hartman, A. N., Mehta, S. J., Zheng, Y., Ghai, N. R., McLerran, D. F., Chubak, J., ... & Doubeni, C. A. (2016). Racial/ethnic disparities in colorectal cancer screening across healthcare systems. American journal of preventive medicine, 51(4), e107-e115.
Brooke, H. L., Talbäck, M., Martling, A., Feychting, M., & Ljung, R. (2016). Socioeconomic position and incidence of colorectal cancer in the Swedish population. Cancer epidemiology, 40, 188-195.
Cancer Research UK. Bowel cancer incidence by sex and UK country. Retrieved June 1, 2016, from http://www.cancerresearchuk.org/health-professional/cancer- statistics/statistics-by-cancer-type/bowel-cancer/incidence#heading-Zero.
Chen, P. C., Lee, J. C., & Wang, J. D. (2015). Estimation of Life-Year Loss and Lifetime Costs for Different Stages of Colon Adenocarcinoma in Taiwan. PloS one, 10(7), e0133755.
Department of Health. National Bowel Cancer Screening Program (NBCSP). Retrieved August 10, 2016, from https://www.bowelcanceraustralia.org/national-bowel-cancer-screening-program.
Egeberg, R., Halkjær, J., Rottmann, N., Hansen, L., & Holten, I. (2008). Social inequality and incidence of and survival from cancers of the colon and rectum in a population-based study in Denmark, 1994–2003. European Journal of Cancer, 44(14), 1978-1988.
Ferlay J, Parkin DM, Steliarova-Foucher E. Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer 2010;46:765–81.
Fedewa, S. A., Goodman, M., Flanders, W. D., Han, X., Smith, R. A., M Ward, E., ... & Jemal, A. (2015). Elimination of cost‐sharing and receipt of screening for colorectal and breast cancer. Cancer, 121(18), 3272-3280.
Ferlay, J., Soerjomataram, I., Dikshit, R., Eser, S., Mathers, C., Rebelo, M., ... & Bray, F. (2015). Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. International journal of cancer, 136(5), E359-E386.
Greiner, K. A., Engelman, K. K., Hall, M. A., & Ellerbeck, E. F. (2004). Barriers to colorectal cancer screening in rural primary care. Preventive medicine, 38(3), 269-275.
Hardcastle, J. D., Chamberlain, J. O., Robinson, M. H., Moss, S. M., Amar, S. S., Balfour, T. W., ... & Mangham, C. M. (1996). Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. The Lancet, 348(9040), 1472-1477.
Jemal, A., Siegel, R. L., Ma, J., Islami, F., DeSantis, C., Sauer, A. G., ... & Ward, E. M. (2014). Inequalities in premature death from colorectal cancer by state. Journal of Clinical Oncology, JCO-2014.
Kelsall, H. L., Baglietto, L., Muller, D., Haydon, A. M., English, D. R., & Giles, G. G. (2009). The effect of socioeconomic status on survival from colorectal cancer in the Melbourne Collaborative Cohort Study. Social science & medicine, 68(2), 290-297.
Kronborg, O., Fenger, C., Olsen, J., Jørgensen, O. D., & Søndergaard, O. (1996). Randomised study of screening for colorectal cancer with faecal-occult-blood test. The Lancet, 348(9040), 1467-1471.
Lee, W., Nelson, R., Mailey, B., Duldulao, M. P., Garcia-Aguilar, J., & Kim, J. (2012). Socioeconomic factors impact colon cancer outcomes in diverse patient populations. Journal of Gastrointestinal Surgery, 16(4), 692-704.
Liss, D. T., & Baker, D. W. (2014). Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care. American journal of preventive medicine, 46(3), 228-236.
Mandel, J. S., Bond, J. H., Church, T. R., Snover, D. C., Bradley, G. M., Schuman, L. M., & Ederer, F. (1993). Reducing mortality from colorectal cancer by screening for fecal occult blood. New England Journal of Medicine, 328(19), 1365-1371.
Mandel, J. S., Church, T. R., Ederer, F., & Bond, J. H. (1999). Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. Journal of the National Cancer Institute, 91(5), 434-437.
Meester, R. G., Doubeni, C. A., Zauber, A. G., Goede, S. L., Levin, T. R., Corley, D. A., ... & Lansdorp‐Vogelaar, I. (2015). Public health impact of achieving 80% colorectal cancer screening rates in the United States by 2018. Cancer, 121(13), 2281-2285.
Møller, H., Sandin, F., Robinson, D., Bray, F., Klint, Å., Linklater, K. M., ... & Morris, E. (2012). Colorectal cancer survival in socioeconomic groups in England: variation is mainly in the short term after diagnosis. European Journal of Cancer, 48(1), 46-53.
National Cancer Institute (n.d.). Colon Cancer Treatment (PDQ®)–Patient Version. Retrieved August 10, 2016, from http://www.cancer.gov/types/colorectal/ patient/colon-treatment-pdq#section/all.
National Health Service (n.d.). Bowel cancer screening. Retrieved August 10, 2016, from http://www.nhs.uk/ Conditions/bowel-cancer-screening/Pages/ Introduction.aspx.
Rutherford, M. J., Abel, G. A., Greenberg, D. C., Lambert, P. C., & Lyratzopoulos, G. (2015). The impact of eliminating age inequalities in stage at diagnosis on breast cancer survival for older women. British journal of cancer, 112, S124-S128.
Suh, M., Choi, K. S., Lee, H. Y., Hahm, M. I., Lee, Y. Y., Jun, J. K., & Park, E. C. (2015). Socioeconomic disparities in colorectal cancer screening in Korea: a nationwide cross-sectional study. Medicine, 94(39).
The Surveillance, Epidemiology, and End Results. Colon and Rectum Cancer Number of New Cases and Deaths Per 100,000 People (All Races, Males and Females), Age-Adjusted. Retrieved June 1, 2016, from https://seer.cancer.gov/statfacts/html/ld/colorect.html
Tervonen, H. E., Walton, R., Roder, D., You, H., Morrell, S., Baker, D., & Aranda, S. (2016). Socio-demographic disadvantage and distant summary stage of cancer at diagnosis—A population-based study in New South Wales. Cancer epidemiology, 40, 87-94.
Valeri, L., Chen, J. T., Garcia-Albeniz, X., Krieger, N., VanderWeele, T. J., & Coull, B. A. (2016). The role of stage at diagnosis in colorectal cancer black–white survival disparities: a counterfactual causal inference approach. Cancer Epidemiology Biomarkers & Prevention, 25(1), 83-89.
Wee, L. E., Koh, G. C. H., Chin, R. T., Yeo, W. X., Seow, B., & Chua, D. (2012). Socioeconomic factors affecting colorectal, breast and cervical cancer screening in an Asian urban low-income setting at baseline and post-intervention. Preventive medicine, 55(1), 61-67.
World Cancer Research Fund International (n.d.). Colorectal cancer statistics Retrieved August 10, 2016, from http://www.wcrf.org/int/cancer-facts-figures/data-specific-cancers/colorectal-cancer-statistics#BOTH.
World Health Organization (n.d.). Screening for colorectal cancer. Retrieved August 10, 2016, from http://www.who.int/cancer/detection/colorectalcancer/en/.
World Health Organization (n.d.). The top 10 causes of death. Retrieved August 10, 2016, from http://www.wh-o.int/mediacentre/factsheets/fs310/en/index1.html.
大腸癌歷年發生率及死亡率（105年版）。台北市：衛生福利部國民健康署，取自：http://www.hpa.gov.tw/BHPNet/ eb/ealthtopic/opicArticle.aspx?No=200907210002&parentid=200802140005
陳怡君、吳坤和、林為森：高雄地區民眾大腸癌糞便潛血篩檢行為及其影響因子。嘉南學報 2010；36；p.291-301。
衛生福利部國民健康署：大腸癌防治概況。衛生福利部國民健康署，取自：https://www.hpa.gov.tw/Pages/Detail.aspx?nodeid=615&pid=1126
衛生福利部國民健康署：大腸癌篩檢暨陽性個案後續追蹤衛教指引。衛生福利部國民健康署：2014。
衛生福利部國民健康署：第二期國家癌症防治計畫- 癌症篩檢(99-102 年)。衛生福利部國民健康署：2009。
衛生福利部國民健康署：第三期國家癌症防治計畫（103-107 年。衛生福利部國民健康署：2015。
衛生福利部國民健康署：第三期國家癌症防治計畫（104年評核報告），取自：http://117.56.91.94/KMPublicreaddocu mentaspx?documentId=254399.
衛生福利部國民健康署：癌症登記線上互動查詢系統。衛生福利部國民健康署，取自：https://cris.hpa.gov.tw.