NcXHF

VALUE OF LUNG CANCER CT SCREENING
nations indicate that insurance coverage will no longer be a
barrier to screening implementation for insured individuals.
New screening programs will likely proliferate across the nation,
because hospitals now realize an opportunity to increase
revenues by offering lung cancer CT screening and performing
downstream tests and procedures prompted by a positive
screening result. 24,25
From a pragmatic standpoint, lung cancer CT screening
will gradually become routine practice. Stakeholders should
focus now on developing implementation strategies to ensure
that lung cancer CT screening will add value to society
despite the potentially high costs. 24,26,27 The next sections will
discuss how implementation can influence the value of CT
screening and what measures can be taken to increase the
benefıts of screening per dollar spent.
VALUE AND IMPLEMENTATION
Value in health care is a concept that links the benefıts of a
given intervention with its costs. 28 Cost-effectiveness analysis
is a type of health economic evaluation that provides a
value metric, usually defıned as a ratio of additional costs to
additional benefıts of a new intervention compared with
usual care (i.e., the incremental cost-effectiveness ratio or
ICER). 29
Previous cost-effectiveness analysis failed to provide conclusive
evidence about the cost-effectiveness of lung cancer
CT screening in the U.S. population. 12,13,26,30-34 Most of these
modeling studies were poised by multiple sources of bias, because
their estimates of screening effectiveness came from
nonrandomized trials, and the model assumptions often
were overly optimistic. Besides methodologic limitations, the
analyses achieved highly variable results; some suggested that
CT screening is highly cost-effective, whereas others showed
that screening was prohibitively costly.
The NLST team recently published their trial-based costeffectiveness
analysis. 35 This analysis compared the costs and
outcomes of three annual CT screening exams against a
no-screening strategy, assuming that screening chest radiographs
result in equal outcomes compared with no screening.
36 This study probably provides the most accurate
KEY POINTS
Lung cancer computed tomography (CT) screening will
become routine practice.
Lung cancer CT screening will be an expensive public
health investment.
The value of CT screening in practice will depend on the
strategies used to implement it.
Cost-effective implementation of screening will require the
creation of a broad infrastructure.
Physician education, patient counseling, smoking cessation,
and adherence to guidelines should be core elements of a
CT screening implementation plan.
estimate of the cost-effectiveness of CT screening, given that
the analysis derived estimates of effectiveness (tumor stage
shift, life expectancy, and quality-adjusted life years
[QALYs]) from randomized data obtained from more than
50,000 participants. Additional strengths included the availability
of quality-of-life data from a sample of 12,000 participants
and detailed information about health care resource
utilization in patients diagnosed with lung cancer or those
who had a positive screening result.
Compared with no screening, CT screening resulted in additional
U.S. $52,000 per life-year gained (95% CI, $34,000 to
$106,000) and $81,000 per QALY gained (95% CI, $52,000 to
$186,000), respectively. Subgroup analysis suggested that CT
screening is far more cost-effective when performed in individuals
with higher risks for lung cancer. For example, CT
screening resulted in additional $43,000 per QALY gained in
current smokers compared with $615,000 per QALY gained
in former smokers. Similarly, CT screening costs an additional
$169,000 per QALY gained in individuals within the
lowest lung cancer risk quintile compared with $52,000 per
QALY gained in those within the highest risk quintile.
The NLST cost-effectiveness analysis indicates that CT
screening is cost-effective under a commonly accepted
willingness-to-pay threshold of U.S. $100,000 per QALY and
in the context of a randomized trial. 37,38 Despite these encouraging
results, some limitations of this analysis preclude a
conclusion of whether CT screening will be cost-effective in
practice. Sensitivity analysis showed that the cost-effectiveness
estimates highly depended on the assumptions made. For example,
the authors assumed that CT screening would only
affect life expectancy through early detection of lung cancer.
If CT screening would have other positive effects on life expectancy,
perhaps through a favorable impact on smoking
cessation, the ICER would be $54,000 per QALY. Conversely,
CT screening would be less cost-effective ($96,000 per
QALY) if the cost of managing incidental fındings was $2,500
instead of $500, as assumed by the authors. In addition, the
study evaluated the cost-effectiveness of only three annual
CT scans, but current guidelines recommend annual CT
screening for “as long as the patients are eligible,” which will
consist of more than three scans for most screened patients.
4,21 The impact of subsequent CT screening scans on
costs and outcomes beyond 3 years remains an area of research.
Another concerning point is that screening will be
less cost-effective in practice if screening programs underperform
in relation to NLST centers.
The conclusion, as pointed out by the authors of the NLST
cost-effectiveness analysis, is that “whether screening outside
the trial will be cost-effective will depend on how screening is
implemented.” 35 In other words, CT screening will be a valuable
intervention if an infrastructure is in place to provide
patients with high-quality screening services, but policy
makers have questioned whether health care institutions currently
have the capacity of offering these services. This concern
is of upmost importance, because CT screening will be
an onerous health care investment. Large-scale screening
implementation is expected to cost $1.4 to $5.5 billion per
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