Risk-Targeted Lung Cancer Screening A Cost-Effectiveness Analysis

Background:

Targeting low-dose computed tomography (LDCT) for lung cancer screening to persons at highest risk for lung cancer mortality has been suggested to improve screening efficiency.

Objective:

To quantify the value of risk-targeted selection for lung cancer screening compared with National Lung Screening Trial (NLST) eligibility criteria.

Design:

Cost-effectiveness analysis using a multistate prediction model.

Data Sources:

NLST.

Target Population:

Current and former smokers eligible for lung cancer screening.

Time Horizon:

Lifetime.

Perspective:

Health care sector.

Intervention:

Risk-targeted versus NLST-based screening.

Outcome Measures:

Incremental 7-year mortality, life expectancy, quality-adjusted life-years (QALYs), costs, and cost-effectiveness of screening with LDCT versus chest radiography at each decile of lung cancer mortality risk.

Results of Base-Case Analysis:

Participants at greater risk for lung cancer mortality were older and had more comorbid conditions and higher screening-related costs. The incremental lung cancer mortality benefits during the first 7 years ranged from 1.2 to 9.5 lung cancer deaths prevented per 10 000 person-years for the lowest to highest risk deciles, respectively (extreme decile ratio, 7.9). The gradient of benefits across risk groups, however, was attenuated in terms of life-years (extreme decile ratio, 3.6) and QALYs (extreme decile ratio, 2.4). The incremental cost-effectiveness ratios (ICERs) were similar across risk deciles ($75 000 per QALY in the lowest risk decile to $53 000 per QALY in the highest risk decile). Payers willing to pay $100 000 per QALY would pay for LDCT screening for all decile groups.

Results of Sensitivity Analysis:

Alternative assumptions did not substantially alter our findings.

Limitation:

Our model did not account for all correlated differences between lung cancer mortality risk and quality of life.

Conclusions:

Although risk targeting may improve screening efficiency in terms of early lung cancer mortality per person screened, the gains in efficiency are attenuated and modest in terms of life-years, QALYs, and cost-effectiveness.

Primary Funding Source:

National Institutes of Health (U01NS086294).

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