Cost-Effectiveness of Computed Tomography Screening for Lung Cancer in the United States

Abstract

Introduction A randomized trial has demonstrated that lung cancer screening reduces mortality. Identifying participant and program characteristics that influence the cost-effectiveness of screening will help translate trial results into benefits at the population level. Methods Six U.S. cohorts (males and females aged 50, 60, or 70) were simulated in an existing patient-level lung cancer model. Smoking histories reflected observed U.S. patterns. We simulated lifetime histories of 500,000 identical individuals per cohort in each scenario. Costs per quality-adjusted life-year gained ($/QALY) were estimated for each program: CT screening; stand-alone smoking cessation therapies (4–30% 1-year abstinence); and combined programs. Results Annual screening of current and former smokers aged 50–74 cost between $126,000–$169,000/QALY (minimum 20 pack-years of smoking) or $110,000–$166,000/QALY (40 pack-year minimum), compared to no screening and assuming background quit rates. Screening was beneficial but had a higher cost per QALY when the model included radiation-induced lung cancers. If screen participation doubled background quit rates, the cost of annual screening (at age 50, 20 pack-year minimum) was below $75,000/QALY. If screen participation halved background quit rates, benefits from screening were nearly erased. If screening had no effect on quit rates, annual screening cost more but provided fewer QALYs than annual cessation therapies. Annual combined screening/cessation therapy programs at age 50 cost $130,500–$159,700/QALY, compared to annual stand-alone cessation. Conclusions The cost-effectiveness of CT screening will likely be strongly linked to achievable smoking cessation rates. Trials and further modeling should explore the consequences of relationships between smoking behaviors and screen participation.

Cost-Effectiveness of CT Screening in the National Lung Screening Trial

“…30 Much of the difference between our estimate of ICER and the substantially higher estimate reported by McMahon et al 31 can be explained by the difference in the number of follow-up CT scans per positive screening examinationapproximately one observed in the NLST, 32 as compared with four assumed in the study by McMahon et al Much of the difference between our estimate and the lower estimate reported by Pyenson et al 33 can be explained by their assumption that the reduction in mortality from lung cancer that resulted from screening would be higher than the 20% observed in the NLST.…”

“…The ICER rose substantially when we included future health care costs of survivors that were unrelated to lung cancer, but we did not include these costs in our base case because their inclusion is controversial 12 and because they have not been included in prior cost-effectiveness analyses of lung-cancer screening. [7][8][9][10]31,33,35 The ICER also rose substantially when we increased the costs of the screening examination, follow-up, and surgery and when we reduced the quality of life related to positive screening results and to a diagnosis of stage IA lung cancer.…”

Annual number of lung cancer deaths potentially avertable by screening in the United States

“…The large variations noted among the existing estimates have prohibited researchers and policymakers from drawing a firm conclusion regarding the cost-effectiveness of LDCT screening. [11][12][13][14][15][16] Based on the number needed to screen to prevent 1 death from lung cancer in the NLST, Goulart et al estimated that the additional cost of LDCT screening to avoid 1 lung cancer death is $240,000.…”

The Inconclusive Evidence on CT Screening for Lung Cancer

“…Estimates of the cost-effectiveness of CT screening depend on assumptions such as the cost of the screening CT, the false-positive rate, the number and type of diagnostic tests and procedures and their costs, the stage distribution of cancers detected, treatment methods and costs, and mortality rates. Whereas previous studies found that the cost per quality-adjusted life year saved would be less than $50,000 (the amount at present generally accepted as the upper limit for being cost-effective) [27,28], studies using NLST data estimate substantially higher costs [29,30]. A pending cost-effectiveness analysis from the NLST, based on cost data collected from actual screening, should provide even more realistic estimates.…”