Cost-Effectiveness of the Children's Oncology Group Long-Term Follow-up Screening Guidelines for Childhood Cancer Survivors at Risk for Treatment-Related Heart Failure

Abstract

Background Childhood cancer survivors treated with anthracyclines are at high risk for asymptomatic left ventricular dysfunction (ALVD), subsequent heart failure (HF), and death. The consensus-based Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines recommend lifetime echocardiographic screening for ALVD. Objective To evaluate the efficacy and cost-effectiveness of the COG Guidelines and to identify more cost-effective screening strategies. Design Simulation of life-histories using Markov health states. Data Sources Childhood Cancer Survivor Study; published literature. Target Population Childhood cancer survivors. Time Horizon Lifetime. Perspective Societal. Intervention Echocardiographic screening, followed by angiotensin-converting enzyme (ACE) inhibitor and beta-blocker therapies after ALVD diagnosis. Measurements Quality-adjusted life years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and the cumulative incidence of HF. Results of Base-Case Analysis The COG Guidelines versus no screening have an ICER of $61,500, extend life expectancy by 6 months and QALYs by 1.6 months, and reduce the cumulative incidence of HF by 18% at 30 years after cancer diagnosis. However, less-frequent screenings are more cost-effective than the Guidelines, and maintain 80% of the health benefits. Results of Sensitivity Analysis The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER. Limitation Lifetime non-HF mortality and the cumulative incidence of HF more than 20 years after diagnosis were extrapolated; the efficacy of ACE inhibitor and beta-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown). Conclusion The COG Guidelines could reduce the risk of HF in survivors at less than $100,000/QALY. Less-frequent screening achieves most of the benefits and would be more cost-effective than the COG Guidelines. Primary Funding Source Lance Armstrong Foundation, National Cancer Institute.

Anthracycline‐Induced Cardiomyopathy in Adults

“…These guidelines advise repeated echocardiograms every year to every 5 years in all childhood cancer survivors treated with anthracyclines, depending on 12 risk profiles including the age at which the child was treated, the cumulative anthracycline dose, the presence of preexisting cardiac disease and the existence of additional radiation therapy. Two cost-effective studies have recently challenged these guidelines and proposed a reduction in the frequency of monitoring (210,216).…”

Trastuzumab-Induced Cardiotoxicity: Testing a Clinical Risk Score in a Real-World Cardio-Oncology Population

“…Any strategy that uses cardiac imaging faces concerns about cost, which is increasingly scrutinized in the setting of long-term monitoring in cancer survivors 24,25 . We envision an approach to cardiotoxicity risk stratification that incorporates a clinical risk tool, such as the one studied here, in combination with post-chemotherapy cardiac biomarkers and strain imaging.…”

Dexrazoxane for reducing anthracycline-related cardiotoxicity in children with cancer: An update of the evidence

“…Waiting for signs or symptoms of cardiotoxicity to appear is clearly unwise because anthracycline-induced cardiomyopathy is associated with a 2-year mortality rate as high as 60% [40]. Thus, several organizations, including the Children's Oncology Group (COG) in North America, have created comprehensive surveillance guidelines for these patients which involves periodic lifetime screening based upon age at treatment, cumulative anthracycline dosage and whether or not the heart was irradiated [31,42,44,[46][47][48][49]. In addition to taking a medical history, a physical examination for cardiovascular symptoms and signs of heart failure, long-term, periodic electrocardiographic and echocardiographic monitoring, especially of LV systolic function, is also recommended.…”