The National Lung Screening Trial (NLST) showed that screening with low-dose computed tomography (LD-CT) as compared with chest radiography reduced lung cancer mortality. In a study reported in the 6th November 2014 issue of the New England Journal of Medicine, the researchers reported that lung cancer screening in the NLST study meets a commonly accepted standard for cost-effectiveness.
In the latest study, the researchers estimated mean life-years, quality-adjusted life-years (QALYs), costs per person, and incremental cost-effectiveness ratios (ICERs) for three alternative strategies: screening with LD-CT, screening with radiography, and no screening.
Estimations of life-years were based on the number of observed deaths that occurred during the trial and the projected survival of persons who were alive at the end of the trial. Quality adjustments were derived from a subgroup of participants who were selected to complete quality-of-life surveys. Costs were based on utilisation rates and Medicare reimbursements. They also performed analyses of subgroups defined according to age, sex, smoking history, and risk of lung cancer and performed sensitivity analyses based on several assumptions.
The study found that screening for lung cancer with LD-CT would cost 81,000 USD per QALY gained. For policy makers, this ratio establishes relative worth from an economic perspective. A proposed benchmark for cost-effectiveness is 100,000 USD-150,000 USD QALY.
When the researchers looked at specific subgroups of study participants, they found lung cancer screening was most cost-effective for current smokers, women, and for people in their sixties.
Cost-effectiveness on screening outside clinical trials will depend on how it is implemented
The researchers concluded that the determination of whether screening outside the clinical trials will be cost-effective will depend on how screening is implemented.
Lung cancer screening is not yet standard medical practice. Over the last two years, multiple professional associations have issued statements that recommend physicians offer annual lung cancer screening to individuals 55-80 years old who have more than a 30 pack-year history of smoking.
As a result of a positive recommendation (Grade B) handed down by the USA Preventive Services Task Force in December 2013, commercial insurers will be required to cover the test as a preventive service with no co-pays or deductibles. A preliminary panel recommended against coverage by the Centers for Medicare and Medicaid Services (CMS). However, the CMS announced on 11 November 2014 their final decision: there is sufficient evidence to cover lung cancer screening with LD-CT screening for individuals at high risk for lung cancer.
Under the proposed decision, annual LD-CT screening for lung cancer will be covered for individuals aged 55 to 74 who have at least a 30 pack-year history of smoking and currently smoke or have quit within the past 15 years.
The study was funded by the USA National Cancer Institute.
Black WC, Gareen IF, Soneji SS, et al. Cost-Effectiveness of CT Screening in the National Lung Screening Trial. N Engl J Med 2014; 371:1793-1802. DOI: 10.1056/NEJMoa1312547