The Cost-Effectiveness of Low-Dose CT Screening for Lung Cancer: Preliminary Results of Baseline Screening

doi:10.1378/chest.124.2.614

Chest

Volume 124, Issue 2, August 2003, Pages 614-621

https://doi.org/10.1378/chest.124.2.614 Get rights and content

Background

Low-dose CT scan screening greatly improves the likelihood of detecting small nodules and, thus, of detecting lung cancer at a potentially more curable stage.

Methods

To evaluate the cost-effectiveness of a single baseline low-dose CT scan for lung cancer screening in high-risk individuals, data from the Early Lung Cancer Action Project (ELCAP) was incorporated into a decision analysis model comparing low-dose CT scan screening of high-risk individuals (ie, those ≥ 60 years with at least 10 pack-years of cigarette smoking and no other malignancies) to observation without screening. Cost-effectiveness was expressed as the incremental cost per year of life saved. The analysis adopted the perspectives of the health-care system. The probability of the different outcomes following the decision either to screen or not to screen an individual at risk was based on data from ELCAP and the Surveillance, Epidemiology, and End Results Registry or published data, respectively. The cost of the screening and treatment of patients with lung cancer was established based on data from the New York Presbyterian Hospital’s financial system. The base-case analysis was conducted under the assumption of similar aggressiveness of screen-detected and incidentally discovered lung cancers and then was followed by multiple sensitivity analyses to relax these assumptions.

Results

The incremental cost-effectiveness ratio of a single baseline low-dose CT scan was $2,500 per year of life saved. The base-case analysis showed that screening would be expected to increase survival by 0.1 year at an incremental cost of approximately $230. Only when the likelihood of overdiagnosis was > 50% did the cost effectiveness ratio exceed $50,000 per year of life saved. The cost-effectiveness ratios were also relatively insensitive to estimates of the potential lead-time bias.

Conclusions

A baseline low-dose CT scan for lung cancer screening is potentially highly cost-effective and compares favorably to the cost-effectiveness ratios of other screening programs.

Section snippets

Decision-Analytic Model

We evaluated the cost-effectiveness of a program consisting of a single baseline low-dose screening CT scan for the diagnosis of non-small cell lung cancer in persons aged ≥ 60 years with at least a 10-pack-year history of smoking, fit to undergo thoracic surgery, and with no prior history of cancer (except nonmelanoma cancer of the skin). The comparison program, used to represent the alternative base case, was usual care, under which lung cancer is detected by symptoms and/or signs or is

Results

Based on the ELCAP results, we assumed that 233 of 1,000 subjects will have 1 to 6 noncalcified nodules, and that 27 individuals will receive diagnoses of non-small cell lung cancer on baseline CT scan screening. Table 1 shows the number of diagnostic CT scans and FNAs that were performed as part of the workup of subjects with a positive test result.

The stage distribution of lung cancers diagnosed under usual care was significantly different from that identified by CT scan screening. As shown

Discussion

Our analysis suggested that the cost-effectiveness ratio of a single baseline CT scan for the lung cancer screening of high-risk individuals is likely to be within the range of practice and policy acceptability, and compares favorably to the cost-effectiveness ratios of other screening programs.²²

The costs and resource utilization used for the analysis were obtained from The New York-Presbyterian Hospital. Local and regional differences in the costs of medical care and treatment modalities for

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Cited by (156)

Are We Underestimating Efficacy and Cost-Efficacy of Population Lung Cancer Computed Tomography Screening?
2022, JTO Clinical and Research Reports
Systematic review of the cost-effectiveness of screening for lung cancer with low dose computed tomography
2022, Lung Cancer
Citation Excerpt :
In all studies that included lead-time in sensitivity analysis the ICER only minimally rose with the addition of a longer lead-time. Overdiagnosis was considered in 27 studies [16,20,22,23,26,28,29,32,35,36,39–43,45–51,53,54,56,57,62]; 21 (77.8%) of these studies were cost-effective, whereas 14/15 (93.3%) studies that did not include overdiagnosis were cost-effective. Of the model-based studies, twenty assumed an uptake of 100% for screening participation [18–20,22,23,25,30,34,35,43,45,48,49,52,55–59,61]; nine did not state the screening participation rate [21,24,26,27,32,36,45,47,60].
Lung cancer (LC) remains a burden for patients and healthcare systems, with most cases only diagnosed once disease is late stage. Screening for LC with low-dose computed tomography (LDCT) has shown a stage shift and led to a lung cancer-specific mortality reduction. Economic evaluations have been conducted which explore the benefits and costs of screening, however, previous systematic reviews concluded results were heterogeneous. LC screening has evolved and there have been further cost-effectiveness analyses conducted.
The aim of this study was to provide an up-to-date systematic review of the cost-effectiveness of LC screening with LDCT.
Databases were searched for full papers published in English 01/1994–02/2022. Inclusion criteria was full economic evaluation of LC screening using LDCT compared to either no screening or chest X-ray.
Forty-five evaluations were identified, three conducted alongside trials and 42 modelling studies. Thirty-nine evaluations (86.7%) found LC screening with LDCT to be cost-effective. Several findings were broadly consistent across studies: cost-effectiveness was optimal in those age 55–75 years and smoking history of at least 20 pack-years. Biennial screening was often more cost-effective than annual screening and would likely result in less additional findings and radiation exposure. A smoking cessation intervention alongside screening improved cost-effectiveness, but which intervention was optimal was unclear. Risk predictions models using more parameters to target participants for screening did not have more benefits than those using age and smoking alone, and cost-effectiveness was equivalent. Cost-effectiveness was sensitive to cost and specificity of LDCT, and disutility associated with screening.
Overall, LC screening with LDCT is cost-effective in a high-risk population. Questions remain regarding risk prediction models, smoking cessation interventions and appropriateness of utility values in the screened population. Once these uncertainties are addressed, further economic evaluation may be required to inform policymakers prior to implementation.
Variation in Model-Based Economic Evaluations of Low-Dose Computed Tomography Screening for Lung Cancer: A Methodological Review
2022, Value in Health
There is significant heterogeneity in the results of published model-based economic evaluations of low-dose computed tomography (LDCT) screening for lung cancer. We sought to understand and demonstrate how these models differ.
An expansion and update of a previous systematic review (N = 19). Databases (including MEDLINE and Embase) were searched. Studies were included if strategies involving (single or multiple) LDCT screening were compared with no screening or other imaging modalities, in a population at risk of lung cancer. More detailed data extraction of studies from the previous review was conducted. Studies were critically appraised using the Consensus Health Economic Criteria list.
A total of 16 new studies met the inclusion criteria, giving a total of 35 studies. There are geographic and temporal differences and differences in screening intervals and eligible populations. Studies varied in the types of models used, for example, decision tree, Markov, and microsimulation models. Most conducted a cost-effectiveness analysis (using life-years gained) or cost-utility analysis. The potential for overdiagnosis was considered in many models, unlike with other potential consequences of screening. Some studies report considering lead-time bias, but fewer mention length bias. Generally, the more recent studies, involving more complex modeling, tended to meet more of the critical appraisal criteria, with notable exceptions.
There are many differences across the economic evaluations contributing to variation in estimates of the cost-effectiveness of LDCT screening for lung cancer. Several methodological factors and evidence needs have been highlighted that will require consideration in future economic evaluations to achieve better agreement.
Favorable incremental cost-effectiveness ratio for lung cancer screening in Italy
2020, Lung Cancer
Lung cancer detection by low-dose computed tomographic screening reduces mortality. However, it is essential to assess cost-effectiveness. We present a cost-effectiveness analysis of screening in Italians at high risk of lung cancer, from the point of view of the Italian tax-payer.
We used a decision model to estimate the cost-effectiveness of annual screening for 5 years in smokers (≥30 pack-years) of 55–79 years. Patients diagnosed in the COSMOS study were the screening arm; patients diagnosed and treated for lung cancer in the Lombardy Region, Italy, constituted the usual care arm. Treatment costs were extracted from our hospital database. Lung cancer survival in screened patients was adjusted for 2-year lead-time bias. Life-years and quality-adjusted life-years were estimated by stage at diagnosis, from which incremental cost-effectiveness ratios per life-year and quality-adjusted life-year gained were estimated.
Base-case incremental cost-effectiveness ratios were 3297 and 2944 euro per quality-adjusted life-year and life-year gained, respectively. Deterministic sensitivity analysis indicated that these values were particularly sensitive to lung cancer prevalence, screening sensitivity and specificity, screening cost, and treatment costs for stage I and IV disease. From the probabilistic sensitivity analysis incremental cost-effectiveness ratios had a 98 % probability of being <25,000 euro (widely-accepted threshold) and a 55 % probability of being <5000 euro.
Low-dose computed tomographic screening is associated with an incremental cost of 2944 euro per life-year gained in high risk population, implying that screening can be introduced in Italy at contained cost, saving the lives of many lung cancer patients.
Incidental Pulmonary Nodules Are Common on CT Coronary Angiogram and Have a Significant Cost Impact
2019, Heart Lung and Circulation
Computed tomography (CT) coronary angiogram (CTCA) is commonly used for diagnostic evaluation of low-moderate risk patients due to its excellent performance and cost-effectiveness. However, previous cost analyses have not factored in the burden of management of pulmonary nodules, which are a common occurrence. We sought to describe the frequency and characteristics of lung nodules on CTCA in an Australian tertiary hospital, and to assess cost impacts.
Consecutive CTCAs performed in the calendar year 2012 were retrospectively identified from the imaging department database. Subjects were excluded if they were under the age of 35, had known malignancy or findings identified prior to CTCA. Patients were stratified on smoking history and nodule size.
Of the 2479 CTCAs included, full-field imaging revealed nodules in 358 patients (13.9%). The nodules were generally small (73% <6 mm), multiple (63%) and in the lower lobe (83.4%). There was no significant difference when stratified for smoking, with 60% of nodules detected in never-smokers. A minimum of 445 subsequent scans was required for nodule surveillance, resulting in an additional overall cost of $63.62 per CTCA. Limited-Field-of-View (L-FOV) would have identified only 22 nodules, with a cost of $6.14 for every CTCA performed, a cost saving of $57 per patient.
Indeterminate pulmonary nodules are a common incidental finding on CTCA and prevalence appears to be independent of smoking status. There is a consequent significant cost burden that has not previously been recognised. Use of L-FOV reduces the number of nodules identified, with a significant cost benefit, but this has to be balanced against the ethical and medico-legal issues inherent in not reconstructing the irradiated lung.
Screening and staging for non-small cell lung cancer by serum laser Raman spectroscopy
2018, Spectrochimica Acta - Part A: Molecular and Biomolecular Spectroscopy
Citation Excerpt :
Currently there are several screening methods for lung cancer including sputum cytology, chest X-ray and CT scan [4]. However, those screening methods have not been applied prevalently due to controversy over their effectiveness and high cost as screening methods [5–8]. Accurate staging is important because treatment options and prognosis differ significantly by stages.
Lung cancer is the leading cause of cancer-related death worldwide. Current clinical screening methods to detect lung cancer are expensive and associated with many complications. Raman spectroscopy is a spectroscopic technique that offers a convenient method to gain molecular information about biological samples. In this study, we measured the serum Raman spectral intensity of healthy volunteers and patients with different stages of non-small cell lung cancer. The purpose of this study was to evaluate the application of serum laser Raman spectroscopy as a low cost alternative method in the screening and staging of non-small cell lung cancer (NSCLC).
The Raman spectra of the sera of peripheral venous blood were measured with a LabRAM HR 800 confocal Micro Raman spectrometer for individuals from five groups including 14 healthy volunteers (control group), 23 patients with stage I NSCLC (stage I group), 24 patients with stage II NSCLC (stage II group), 19 patients with stage III NSCLC (stage III group), 11 patients with stage IV NSCLC (stage IV group). Each serum sample was measured 3 times at different spots and the average spectra represented the signal of Raman spectra in each case. The Raman spectrum signal data of the five groups were statistically analyzed by analysis of variance (ANOVA), principal component analysis (PCA), linear discriminant analysis (LDA), and cross-validation.
Raman spectral intensity was sequentially reduced in serum samples from control group, stage I group, stage II group and stage III/IV group. The strongest peak intensity was observed in the control group, and the weakest one was found in the stage III/IV group at bands of 848 cm⁻¹, 999 cm⁻¹, 1152 cm⁻¹, 1446 cm⁻¹ and 1658 cm⁻¹ (P < 0.05). Linear discriminant analysis showed that the sensitivity to identify healthy people, stage I, stage II, and stage III/IV NSCLC was 86%, 65%, 75%, and 87%, respectively; the specificity was 95%, 94%, 88%, and 93%, respectively; and the overall accuracy rate was 92% (71/77).
The laser Raman spectroscopy can effectively identify patients with stage I, stage II or stage III/IV Non-Small Cell Lung cancer using patient serum samples.

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Chest

Clinical InvestigationsCANCERThe Cost-Effectiveness of Low-Dose CT Screening for Lung Cancer*: Preliminary Results of Baseline Screening

Background

Methods

Results

Conclusions

Section snippets

Decision-Analytic Model

Results

Discussion

Lancet

Am J Med

Am J Med

Chest

Early lung cancer action project

Cancer

Survival curve for cancer patients following treatment

J Am Stat Assoc

The importance of tumor size in prognosis for resected bronchogenic carcinoma

J Surg Oncol

United States life tables: national vital statistics reports

Cost-effectiveness in health and medicine

Clinical economics: a guide to the economic analysis of clinical practices

JAMA

Screening

Small pulmonary nodules: evaluation with repeat CT–preliminary experience

Radiology

Clinical Investigations
CANCER
The Cost-Effectiveness of Low-Dose CT Screening for Lung Cancer^*: Preliminary Results of Baseline Screening