Performance and Cost-Effectiveness of Computed Tomography Lung Cancer Screening Scenarios in a Population-Based Setting: A Microsimulation Modeling Analysis in Ontario, Canada

Abstract

BackgroundThe National Lung Screening Trial (NLST) results indicate that computed tomography (CT) lung cancer screening for current and former smokers with three annual screens can be cost-effective in a trial setting. However, the cost-effectiveness in a population-based setting with >3 screening rounds is uncertain. Therefore, the objective of this study was to estimate the cost-effectiveness of lung cancer screening in a population-based setting in Ontario, Canada, and evaluate the effects of screening eligibility criteria.Methods and FindingsThis study used microsimulation modeling informed by various data sources, including the Ontario Health Insurance Plan (OHIP), Ontario Cancer Registry, smoking behavior surveys, and the NLST. Persons, born between 1940 and 1969, were examined from a third-party health care payer perspective across a lifetime horizon. Starting in 2015, 576 CT screening scenarios were examined, varying by age to start and end screening, smoking eligibility criteria, and screening interval. Among the examined outcome measures were lung cancer deaths averted, life-years gained, percentage ever screened, costs (in 2015 Canadian dollars), and overdiagnosis. The results of the base-case analysis indicated that annual screening was more cost-effective than biennial screening. Scenarios with eligibility criteria that required as few as 20 pack-years were dominated by scenarios that required higher numbers of accumulated pack-years. In general, scenarios that applied stringent smoking eligibility criteria (i.e., requiring higher levels of accumulated smoking exposure) were more cost-effective than scenarios with less stringent smoking eligibility criteria, with modest differences in life-years gained. Annual screening between ages 55–75 for persons who smoked ≥40 pack-years and who currently smoke or quit ≤10 y ago yielded an incremental cost-effectiveness ratio of $41,136 Canadian dollars ($33,825 in May 1, 2015, United States dollars) per life-year gained (compared to annual screening between ages 60–75 for persons who smoked ≥40 pack-years and who currently smoke or quit ≤10 y ago), which was considered optimal at a cost-effectiveness threshold of $50,000 Canadian dollars ($41,114 May 1, 2015, US dollars). If 50% lower or higher attributable costs were assumed, the incremental cost-effectiveness ratio of this scenario was estimated to be $38,240 ($31,444 May 1, 2015, US dollars) or $48,525 ($39,901 May 1, 2015, US dollars), respectively. If 50% lower or higher costs for CT examinations were assumed, the incremental cost-effectiveness ratio of this scenario was estimated to be $28,630 ($23,542 May 1, 2015, US dollars) or $73,507 ($60,443 May 1, 2015, US dollars), respectively.This scenario would screen 9.56% (499,261 individuals) of the total population (ever- and never-smokers) at least once, which would require 4,788,523 CT examinations, and reduce lung cancer mortality in the total population by 9.05% (preventing 13,108 lung cancer deaths), while 12.53% of screen-detected cancers would be over...

Screening for Lung Cancer

“…71 A study published after the systematic review used microsimulation modeling to estimate the cost-effectiveness of lung cancer screening in a population-based setting in Ontario, Canada. 72 Several models were tested with the optimal scenario for screening identified as current and former smokers aged 55 to 75 years with > 40 pack-years of smoking, who were active smokers or had quit smoking < 10 years ago, screened annually. In this group, the incremental cost-effectiveness ratio was $41,136 Canadian dollars ($33,825 US dollars) per life year gained.…”

Treatment capacity required for full‐scale implementation of lung cancer screening in the United States

“…The model has been previously used to inform the USPSTF on the LDCT screening scenario with the most favorable ratio of benefits and harms for a 1950 US birth cohort . Also, it has been used to identify the most cost‐effective scenario for Cancer Care Ontario …”

“…5 Also, it has been used to identify the most cost-effective scenario for Cancer Care Ontario. 12 In the current analysis, we first simulated a scenario without lung cancer screening. Then, we simulated 3 scenarios with screening: 1) using the USPSTF recommendations (ie, annual screening of current smokers and former smokers who quit fewer than 15 years ago, aged 55-80 years, with a smoking history of at least 30 pack-years), 3 2) using the CMS recommendations (ie, stopping screening 3 years earlier than the USPSTF scenario at the age of 77 years), 4 and 3) using the most cost-effective policy from a recent cost-effectiveness analysis for Cancer Care Ontario (ie, annual screening of current smokers and former smokers who quit fewer than 10 years ago, aged 55-75 years, with a smoking history of at least 40 pack-years).…”

Serum biomarkers for lung cancer screening

“…LDCT is the method recommended by the recent guidelines to identify early lung nodules but has several pitfalls that points out the necessity to improve or replace it by less invasive methods that might offer a better costeffectiveness relationship [18][19][20][21] .…”