Evidence-Based Medicine Online First, published on February 25, 2015 as 10.1136/ebmed-2014-110137 Economic analysis

Cost-effectiveness analysis

Lung cancer CT screening is costeffective but implementation matters 10.1136/ebmed-2014-110137

Bernardo Goulart University of Washington, Hutchinson Institute for Cancer Outcomes Research (HICOR), Fred Hutchinson Cancer Research Center, Seattle, Washington, USA Correspondence to: Dr Bernardo Goulart, University of Washington, Hutchinson Institute for Cancer Outcomes Research (HICOR), Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Po Box 19024, Seattle, WA 98109, USA; [email protected]

Commentary on: Black WC, Gareen IF, Soneji SS, et al.; National Lung Screening Trial Research Team. Cost-effectiveness of CT screening in the National Lung Screening Trial. N Engl J Med 2014;37:1793–802.

Context The National Lung Screening Trial (NLST) revealed a 20% reduction in lung cancer mortality from three annual low-dose CT screening scans compared with chest radiographs in high-risk individuals.1 Since up to 10 million individuals in the USA may qualify for annual CT screening, policymakers have legitimately questioned whether the benefits of lung cancer screening justify the potential high costs of large-scale screening implementation. To assess the value of CT screening, Black et al conducted a trial-based cost-effectiveness analysis using the NLST data.

chest X-ray strategy from further analysis. Compared with no screening, CT screening resulted in additional average costs of US$52 000 per life year gained and US$81 000 per quality-adjusted life year (QALY) gained. Subgroup analysis suggested that CT screening is substantially more costeffective in individuals with higher risks for developing lung cancer. The costs per QALY gained were US$43 000 in current smokers versus US $615 000 in former smokers. Similarly, these costs were US$52 000 in individuals at the highest risk quintile versus US$169 000 in the lowest risk quintile, respectively. The sensitivity analysis showed that the costeffectiveness of CT screening highly depends on the assumptions made. For example, CT screening will be more cost-effective (US$54 000 per QALY gained) if it reduces mortality from diseases other than lung cancer. Conversely, CT screening will not be cost-effective (US$110 000 per QALY gained) if the cost of a low-dose CT was US$500 versus US $285 as assumed by the authors.

Commentary Black et al’s analysis is the first to report the cost-effectiveness of lung cancer CT screening based on data from a high-quality randomised trial. The major strength of this analysis is the lack of multiple sources of bias incurred by the eight previous cost-effectiveness analyses of CT screening, all of which were based on observational data. The major limitation of this analysis is that its results may not be generalisable to healthcare settings that do not have the level of screening expertise available at NLST participating centres. Another concern is that this analysis did not evaluate the cost-effectiveness of CT screening beyond three annual scans. Current guidelines recommend annual screening for ‘as long as patients are eligible’, which, for most patients, will consist of more than three CT screening examinations. Additional research is required to determine the impact of subsequent screening examinations on costs and outcomes beyond 3 years. The study assumptions heavily influenced the cost-effectiveness estimates of CT screening. Consequently, whether CT screening will be cost-effective in practice will require a repeat analysis after screening is implemented.

Methods This trial-based cost-effectiveness analysis compared life expectancy, quality-adjusted life expectancy (QALE) and lifetime costs for three strategies: (1) annual CT screening for 3 years; (2) annual chest X-ray screening for 3 years and (3) no screening. The target population consisted of asymptomatic individuals of ages 55–74 years with a minimum smoking history of 30 packs per year, who were current smokers or had quit smoking within 15 years prior to enrolment. The authors estimated life expectancy by adding survival time observed during the NLST study to projected survival beyond the trial period. To adjust life expectancy for quality of life, the authors obtained health utility measures from nearly 12 000 study participants. Cost assessments took the societal perspective (direct and indirect medical costs) and a lifetime horizon; costs were reported in 2009 US dollars. The study included detailed subgroup and sensitivity analyses. To simplify a complex analysis, the authors assumed that: (1) screening had no effect on life expectancy other than through early detection of lung cancer; (2) a clinically significant incidental finding would cost on average US$500; (3) outcomes were equal between the screening chest X-ray and no screening strategies.

Findings Compared with no screening, the chest X-ray screening strategy resulted in higher costs but equal QALE, prompting the authors to exclude the

Implications for practice Lung cancer CT screening is potentially cost-effective under the commonly accepted cost-effectiveness threshold of US$100 000 per QALY, but many factors can make screening substantially more or less costeffective. Screening seems to provide the largest benefits for the dollar spent when performed on patients who are at the highest risk for developing lung cancer. The study by Black et al supports the notion that screening low-risk patients (eg, light smokers) will result in prohibitive high costs and such practice should be strongly discouraged. Cost-effective implementation of CT screening will require more than the availability of a CT scanner; several services will need to be provided to patients, including: (1) counselling about benefits and risks of screening; (2) smoking cessation interventions; (3) an experienced multidisciplinary team in the management of positive screening results. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.

Reference 1. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395–409.

Evid Based Med Month 2015 | volume 0 | number 0 |

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Lung cancer CT screening is cost-effective but implementation matters.

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