Evaluating lung cancer screening in China: Implications for eligibility criteria design from a microsimulation modeling approach

Abstract

More than half of males in China are current smokers and evidence from western countries tells us that an unprecedented number of smoking-attributable deaths will occur as the Chinese population ages. We used the China Lung Cancer Policy Model (LCPM) to simulate effects of computed tomography (CT)-based lung cancer screening in China, comparing the impact of a screening guideline published in 2015 by a Chinese expert group to a version developed for the United States by the U.S. Centers for Medicare & Medicaid Services (CMS). The China LCPM, built using an existing lung cancer microsimulation model, can project population outcomes associated with interventions for smoking-related diseases. After calibrating the model to published Chinese smoking prevalence and lung cancer mortality rates, we simulated screening from 2016 to 2050 based on eligibility criteria from the CMS and Chinese guidelines, which differ by age to begin and end screening, pack-years smoked, and years since quitting. Outcomes included number of screens, mortality reduction, and life-years saved for each strategy. We projected that in the absence of screening, 14.98 million lung cancer deaths would occur between 2016 and 2050. Screening with the CMS guideline would prevent 0.72 million deaths and 5.8 million life-years lost, resulting in 6.58% and 1.97% mortality reduction in males and females, respectively. Screening with the Chinese guideline would prevent 0.74 million deaths and 6.6 million life-years lost, resulting in 6.30% and 2.79% mortality reduction in males and females, respectively. Through 2050, 1.43 billion screens would be required using the Chinese screening strategy, compared to 988 million screens using the CMS guideline. In conclusion, CT-based lung cancer screening implemented in 2016 and based on the Chinese screening guideline would prevent about 20,000 (2.9%) more lung cancer deaths through 2050, but would require about 445 million (44.7%) more screens than the CMS guideline.

A simulation study of the effect of lung cancer screening in China, Japan, Singapore, and South Korea

“…[13] If implemented in China with full adherence, these screening guidelines would prevent about 20,000 (2.9%) more lung cancer deaths in China through 2050 than the CMS guidelines would, but at a price of about 445 million (44.7%) more screens. [40] A combination of tobacco control programs and a lung cancer screening guideline fitted to the population would likely be most effective in China, as is corroborated by our previous study reporting a greater mortality reduction rate if smoking cessation interventions were added to an annual lung cancer screening program in the United States. [34]…”

Challenges and research opportunities for lung cancer screening in China

“…Although statistical significance was not achieved because of the small sample size, the results showed a 17% reduction in overall mortality and a 30% reduction in lung cancer-specific mortality with LDCT. Two simulation studies that favored LDCT screening in China were also published this year, and similar conclusions were reached, although different models and parameters were used [ 3 , 4 ].…”

“…A major conclusion of the two recent studies [ 3 , 4 ] on lung cancer screening in China was the emphasis on deliberately selecting candidates for screening. According to a study published by Katki et al [ 11 ] in 2016, several screening effectiveness and efficiency metrics (e.g., number needed to screen to prevent one lung cancer death) could be optimized in the US with a “risk-based approach” for selecting the high-risk population.…”

“…With a micro-simulation model adapted from the US National Cancer Institute, Sheehan et al [ 3 ] predicted the effects of lung cancer screening with LDCT in China between 2016 and 2050 and published their results in March 2017. Screening effects were compared between screening eligibility criteria defined in the 2015 Chinese lung cancer screening guidelines [ 5 ] as well as in the US version [ 6 ].…”

The challenges of implementing low-dose computed tomography for lung cancer screening in low- and middle-income countries

“…Inclusion criteria for screening have a major impact on cost-effectiveness 122 . For example, micro-simulation models comparing the use of the Chinese guidelines with those of the US Centers of Medicare and Medicaid Services concluded that the application of local recommendations would result in 50% improvement in mortality reduction in females (2.79% versus 1.97%), saving an additional 20,000 lives in China by 2050, but only if almost 50% more screenings were performed 123 . In such cases, RPM utilization could optimize screening eligibility and effectiveness, possibly resulting in a substantial reduction in budget impact and making LDCT screening eventually cost-saving if non-curative treatment costs continue to rise 97 .…”