Lung cancer screening by low-dose computed tomography: a cost-effectiveness analysis of alternative programmes in the UK using a newly developed natural history-based economic model

Abstract

Background A systematic review of economic evaluations for lung cancer identified no economic models of the UK setting based on disease natural history. We first sought to develop a new model of natural history for population screening, then sought to explore the cost-effectiveness of multiple alternative potential programmes. Methods An individual patient model (ENaBL) was constructed in MS Excel® and calibrated against data from the US National Lung Screening Trial. Costs were taken from the UK Lung Cancer Screening Trial and took the perspective of the NHS and PSS. Simulants were current or former smokers aged between 55 and 80 years and so at a higher risk of lung cancer relative to the general population. Subgroups were defined by further restricting age and risk of lung cancer as predicted by patient self-questionnaire. Programme designs were single, triple, annual and biennial arrangements of LDCT screens, thereby examining number and interval length. Forty-eight distinct screening strategies were compared to the current practice of no screening. The primary outcome was incremental cost-effectiveness of strategies (additional cost per QALY gained). Results LDCT screening is predicted to bring forward the stage distribution at diagnosis and reduce lung cancer mortality, with decreases versus no screening ranging from 4.2 to 7.7% depending on screen frequency. Overall healthcare costs are predicted to increase; treatment cost savings from earlier detection are outweighed by the costs of over-diagnosis. Single-screen programmes for people 55–75 or 60–75 years with ≥ 3% predicted lung cancer risk may be cost-effective at the £30,000 per QALY threshold (respective ICERs of £28,784 and £28,169 per QALY gained). Annual and biennial screening programmes were not predicted to be cost-effective at any cost-effectiveness threshold. Limitations LDCT performance was unaffected by lung cancer type, stage or location and the impact of a national screening programme of smoking behaviour was not included. Conclusion Lung cancer screening may not be cost-effective at the threshold of £20,000 per QALY commonly used in the UK but may be cost-effective at the higher threshold of £30,000 per QALY.

Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 Explanation and Elaboration: A Report of the ISPOR CHEERS II Good Practices Task Force

“…Statistical uncertainty associated with economic evaluations undertaken with individual patient data (IPD) can be reflected by reporting confidence intervals or Bayesian credibility intervals of incremental costs and incremental effects. Because confidence or credible intervals can be problematic to estimate and misleading, 141 cost-effectiveness planes and costeffectiveness acceptability curves may be more appropriate Example of Item 17: Analytics and assumptions 134,135 "A summary of . key assumptions around modelling approach [is] in Table 2; .…”

“…Example of Item 24: Effect of uncertainty 134 should also be discussed. Finally, the discussion section should present future research directions.…”

Can we increase efficiency of CT lung cancer screening by combining with CVD and COPD screening? Results of an early economic evaluation

“…This study compared once-off LDCT screening for LC, with the addition of CVD, COPD, or both to no-screening in a stochastic data-based analysis without the involvement of participants. Although annual and biennial screening is more common, a single screening round is considered a starting point and in some cases could be more cost-effective than repeated screening [17].…”

The principles and pitfalls of screening in primary care

“…This is assessed using a cost-effectiveness analysis, which is often complex and debated. Part of the evidence against screening for lung cancer is based on high cost per quality adjusted life year, a cost-effectiveness measure (Griffin et al, 2020). However, the national screening committee is currently reviewing this decision.…”