Trade-off between benefits, harms and economic efficiency of low-dose CT lung cancer screening: a microsimulation analysis of nodule management strategies in a population-based setting

Abstract

BackgroundIn lung cancer screening, a nodule management protocol describes nodule assessment and thresholds for nodule size and growth rate to identify patients who require immediate diagnostic evaluation or additional imaging exams. The Netherlands-Leuvens Screening Trial and the National Lung Screening Trial used different selection criteria and nodule management protocols. Several modelling studies have reported variations in screening outcomes and cost-effectiveness across selection criteria and screening intervals; however, the effect of variations in the nodule management protocol remains uncertain. This study evaluated the effects of the eligibility criteria and nodule management protocols on the benefits, harms and cost-effectiveness of lung screening scenarios in a population-based setting in Germany.MethodsWe developed a modular microsimulation model: a biological module simulated individual histories of lung cancer development from carcinogenesis onset to death; a screening module simulated patient selection, screening-detection, nodule management protocols, diagnostic evaluation and screening outcomes. Benefits included mortality reduction, life years gained and averted lung cancer deaths. Harms were costs, false positives and overdiagnosis. The comparator was no screening. The evaluated 76 screening scenarios included variations in selection criteria and thresholds for nodule size and growth rate.ResultsFive years of annual screening resulted in a 9.7–12.8% lung cancer mortality reduction in the screened population. The efficient scenarios included volumetric assessment of nodule size, a threshold for a volume of 300 mm3 and a threshold for a volume doubling time of 400 days. Assessment of volume doubling time is essential for reducing overdiagnosis and false positives. Incremental cost-effectiveness ratios of the efficient scenarios were 16,754–23,847 euro per life year gained and 155,287–285,630 euro per averted lung cancer death.ConclusionsLung cancer screening can be cost-effective in Germany. Along with the eligibility criteria, the nodule management protocol influences screening performance and cost-effectiveness. Definition of the thresholds for nodule size and nodule growth in the nodule management protocol should be considered in detail when defining optimal screening strategies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-017-0924-3) contains supplementary material, which is available to authorized users.

Cost-utility analysis of a potential lung cancer screening program for a high-risk population in Germany: A modelling approach

“…Several previous cost-effectiveness studies have yielded similar results for high-risk populations, albeit in Canada and the US. A recently published German microsimulation reported ICERs between € 16,754 and € 23,847 per additional life year depending on the screening protocol [27]. They did not report ICERs after quality adjustment of life years.…”

“…Evidence from Germany is limited to a study by Treskova et al which focuses primarily on comparing the NLST and NELSON trial screening protocols. Using microsimulation, treatment costs based on UK cost data, and a high adherence rate compared to other cancer screening programs, the authors calculate incremental cost-effectiveness ratios (ICERs) between € 16,754 and € 23,847 per life year gained, depending on the screening protocol [27].…”

Estimating the Cost-Effectiveness of Lung Cancer Screening with Low-Dose Computed Tomography for High-Risk Smokers in Australia

“…38 As found in previous reports, this highlights the importance of factors affecting the number of screens within a program (e.g., the optimal screening interval and the definition of screening results requiring follow-up scans). 32,34 One of the biggest factors affecting both the number of scans and cost-effectiveness of lung screening is the criteria used for screening eligibility.…”

“…The proportion of positive results (both false-positive and true-positive results) has been shown to vary with the age of the cohort and the number of screens. 33,34 In the NLST, more than 20% of LDCT participants required follow-up after their first screen, and in approximately 25% of surgical procedures, the nodule was determined to be benign. 2 Since the NLST, there have been advances in nodule management strategies that have aimed to reduce the number of false-positive results in a screening program.…”

“…We evaluated current and past smokers separately, in addition to evaluating an eligibility criterion of a 40-pack-year smoking history as an alternative to the 30-pack-year NLST criterion (as in previous studies). [32][33][34]…”