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Cost-effectiveness of CT screening in the National Lung Screening Trial
William C Black1, Ilana F Gareen, Samir S Soneji
1From the Department of Radiology (W.C.B.), Dartmouth Institute for Health Policy and Clinical Practice (S.S.S.), and Norris Cotton Cancer Center (S.S.S.), Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Center for Statistical Sciences (I.F.G., J.D.S., J.G., C.G.), Department of Epidemiology (I.F.G.), and Department of Biostatistics (C.G.), Brown University School of Public Health, Providence, RI; Pardee RAND Graduate School, Santa Monica, CA (E.B.K.); Department of Radiological Sciences (D.R.A.) and Divisions of Hematology-Oncology and Geriatric Medicine, Department of Medicine (A.N.), David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; Division of Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis (T.R.C.); and Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston (G.A.S.).
Background:
The National Lung Screening Trial (NLST) showed that screening with low-dose computed tomography (CT) as compared with chest radiography reduced lung-cancer mortality. We examined the cost-effectiveness of screening with low-dose CT in the NLST.
Methods:
We estimated mean life-years, quality-adjusted life-years (QALYs), costs per person, and incremental cost-effectiveness ratios (ICERs) for three alternative strategies: screening with low-dose 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 utilization rates and Medicare reimbursements. We 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.
Results:
As compared with no screening, screening with low-dose CT cost an additional $1,631 per person (95% confidence interval [CI], 1,557 to 1,709) and provided an additional 0.0316 life-years per person (95% CI, 0.0154 to 0.0478) and 0.0201 QALYs per person (95% CI, 0.0088 to 0.0314). The corresponding ICERs were $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). However, the ICERs varied widely in subgroup and sensitivity analyses.
Conclusions:
We estimated that screening for lung cancer with low-dose CT would cost $81,000 per QALY gained, but we also determined that modest changes in our assumptions would greatly alter this figure. The determination of whether screening outside the trial will be cost-effective will depend on how screening is implemented. (Funded by the National Cancer Institute; NLST ClinicalTrials.gov number, NCT00047385.).
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