1. In this study comparing three prominent lung cancer screening strategies, all were found to be cost-effective, yielding incremental cost-effectiveness ratios of under $100,000/quality adjusted life-year gained, the commonly referenced U.S. willingness-to-pay threshold.
2. As the maximum age for screening eligibility increased, greater reductions in cancer mortality were realized but at the expense of overdiagnosis rates and treatment costs.
Evidence Rating Level: 2 (Good)
Study Rundown: Lung cancer screening has been shown to be effective in reducing mortality, but recommendations vary regarding the maximum age at which benefits of screening outweigh harms: 80 years according to the U.S. Preventive Services Task Force (USPSTF), 77 years according to the Centers for Medicare & Medicaid Services (CMS), and 74 years according to the National Lung Screening Trial (NLST). As the number of persons eligible for screening continues to increase, it has become essential to evaluate the lung cancer and cost outcomes generated by various screening alternatives. A significant number of studies have been conducted investigating the cost-effectiveness of various screening strategies, but it has remained difficult to draw conclusions because of inconsistencies with established guidelines. This study utilized four independent microsimulation models to compare cost, effectiveness, and cost-effectiveness outcomes based on the USPSTF, CMS, and NLST eligibility criteria, finding that all three strategies resulted in potential quality-adjusted life-years (QALYs) gained at acceptable cost versus no screening. Of the three, only USPSTF guidelines were not conclusively cost-effective according to all four models, underscoring the importance of assessing the upper age limit of any given screening program. Finally, in probabilistic sensitivity analysis considering uncertainties in quality of life and cost inputs, the NLST strategy had the highest likelihood of being cost-effective while the CMS strategy yielded the most optimal outcomes (greatest increase in QALY gained and the greatest reduction in lung cancer mortality). A limitation of this study was failure to incorporate risk-based screening as a potential alternative.
In-Depth [retrospective cohort]: This study sought to analyze the cost-effectiveness of different stopping ages for lung cancer screening with low dose computed tomography (LDCT). Four independent microsimulation models were developed in order to maximize robustness as well as allow for cross-validation, and each was calibrated extensively to reproduce data from existing U.S. epidemiologic studies. Cost inputs were also standardized and included those related to diagnostic procedures as well as treatment. The primary outcome was the incremental cost-effectiveness ratio (ICER), and secondary outcomes included mortality reduction and overdiagnosis. Cost-effectiveness was defined as any cost below the willingness-to-pay (WTP) threshold of $100,000/QALY gained. All four models determined that CMS and NLST guidelines would be cost-effective, but only two predicted that USPSTF guidelines would be cost-effective. After aggregating data across all models, screening according to the CMS criteria achieved an average ICER of $68,600 (range, $54300 to $92300) per QALY compared with screening based on the NLST criteria, and screening according to the USPSTF criteria achieved an average ICER of $96,700 (range, $74800 to $122000) per QALY versus screening based on the CMS criteria. Based on 100,000 iterations of the probabilistic sensitivity analysis, the NLST screening strategy had the greatest likelihood (range, 95% to 100%) of being cost-effective, whereas the CMS and USPSTF strategies had a 77% (range, 54% to 91%) and 52% (range, 22% to 74%) probability, respectively. Overall, the USPSTF criteria yielded the greatest benefit at the greatest cost.
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