Limiting lung cancer screening to high-risk former smokers may improve cost-effectiveness at a population level, according to a study published in PLOS Medicine. Regular computed tomography (CT) lung cancer screening of current and former smokers is currently recommended in the US and is being considered in other countries, but the specific criteria (e.g.: smoking history, age) and frequency of screening to achieve optimal cost-effectiveness is debated. In this study, Kevin ten Haaf of the Erasmus MC University Medical Center Rotterdam, the Netherlands, and colleagues used a microsimulation model to analyze 576 different lung cancer screening policies for persons born between 1940 and 1969 in Ontario, Canada. They found that stringent eligibility criteria (such as requiring more years of heavy smoking to qualify for screening) was more cost-effective than less stringent eligibility criteria, and that annual screening would be more cost-effective than biennial screening.
The authors found that the most cost-effective scenario was annual screening between ages 55 and 75 years old for persons who smoked more than 40 pack-years (the number of packs of cigarettes smoked per day multiplied by the number of years the person has smoked) and who quit less than 10 years ago (or currently smoke). They estimate that this screening strategy would reduce lung cancer mortality by 9.05% compared to no screening, with an incremental cost-effectiveness ratio of $41,136 Canadian dollars per life-year gained.
Though the optimal scenario is actually estimated to catch fewer lung cancers than the criteria used in the National Lung Screening Trial (NLST) in the US, the authors predict this more stringent scenario would require fewer CT scans, and lead to fewer false positive screens and lung cancer overdiagnosis, which can lead to patient harm. The authors note that their analyses do not account for impact of increased frequency of screening and follow-up on quality of life of those screened. Additionally, they note that their assumptions for follow-up procedures were based on data from the NLST, and may not be generalizable to a population setting.
Still, the authors say this study "indicates that lung cancer screening can be cost-effective in a population-based setting if stringent smoking eligibility criteria are applied." In an accompanying Perspective, Steven Shapiro of the University of Pittsburgh School of Medicine, United States, discusses the challenges of balancing costs–both monetary and of over-treatment–of frequent and widespread testing with the benefits of early diagnosis.
This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC), Cancer Care Ontario, and the Ontario Institute for Cancer Research. The MISCAN model was developed primarily through public Dutch funding and adapted for the United States through support by Grant 5U01CA152956-04 from the National Cancer Institute as part of the Cancer Intervention and Surveillance Modelling Network (CISNET). HJdK received funding from the Dutch National Institute of Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu) under grant 105223, and HJdK, CMvdA, and KtH received funding from The Netherlands Organization for Health Research and Development (De Nederlandse organisatie voor gezondheidsonderzoek en zorginnovatie) under grant 103346 in support of the MISCAN model. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
I have read the journal's policy and the authors of this manuscript have the following competing interests: Since February 2016 MCT has been a Senior Scientist for Cancer Care Ontario and serves as Scientific Lead on their High Risk Lung Cancer Screening Pilot Study and Program Development. This is a part time position and his primary occupation is as professor at Brock University. Cancer Care Ontario funded the research submitted for publication here. LFP received a restricted research grant from Cancer Care Ontario from 2013 – 2015 for a Health Technology Assessment of CT Lung Screening for a total of $751,000, $200,000 of which was directly spent on the work reported in this publication. HJdK was involved in a Health Technology Assessment study for CT Lung Cancer Screening in Canada (with author LFP, Cancer Care Ontario). HJdK, CMvdA, and KtH are members of the the Cancer Intervention and Surveillance Modeling Network (CISNET) Lung working group (grant 1U01CA199284-01 from the National Cancer Institute). HJdK is the principal investigator of the Dutch-Belgian Lung Cancer Screening Trial (Nederlands-Leuvens Longkanker Screenings onderzoek; the NELSON trial). CMvdA and KtH are researchers affiliated with the NELSON trial. HJdK, CMvdA, and KtH received a grant from the University of Zurich to assess the cost-effectiveness of computed tomographic lung cancer screening in Switzerland. HJdK took part in a one-day advisory meeting on biomarkers organized by M.D. Anderson/Health Sciences during the 16th World Conference on Lung Cancer.
ten Haaf K, Tammemägi MC, Bondy SJ, van der Aalst CM, Gu S, McGregor SE, et al. (2017) Performance and Cost-Effectiveness of Computed Tomography Lung Cancer Screening Scenarios in a Population-Based Setting: A Microsimulation Modeling Analysis in Ontario, Canada. PLoS Med 14(2): e1002225. doi:10.1371/journal.pmed.1002225
Department of Public Health, Erasmus MC–University Medical Center Rotterdam, Rotterdam, the Netherlands
Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
University of Toronto Dalla Lana School of Public Health, Ontario, Canada
Institute for Clinical Evaluative Sciences, Ontario Tobacco Research Unit, Toronto, Ontario, Canada,
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
Population, Public & Indigenous Health, Alberta Health Services, Calgary, Alberta, Canada
The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
IN YOUR COVERAGE PLEASE USE THIS URL TO PROVIDE ACCESS TO THE FREELY AVAILABLE PAPER: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002225
The author received no specific funding for this work.
The author has declared that no competing interests exist.
Shapiro SD (2017) Refining Lung Cancer Screening Criteria in the Era of Value-Based Medicine. PLoS Med 14(2): e1002226. doi:10.1371/journal.pmed.1002226
Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, Pennsylvania, United States of America
IN YOUR COVERAGE PLEASE USE THIS URL TO PROVIDE ACCESS TO THE FREELY AVAILABLE PAPER: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002226
Kevin ten Haaf
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