Performance and Cost-Effectiveness of Computed Tomography Lung Cancer Screening Scenarios in a Population-Based Setting: A Microsimulation Modeling Analysis in Ontario, Canada.
Performance and Cost-Effectiveness of Computed Tomography Lung Cancer Screening Scenarios in a Population-Based Setting: A Microsimulation Modeling Analysis in Ontario, Canada.
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DOI：
10.1371/journal.pmed.1002225
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发表时间：
2017-02
期刊：
影响因子：
15.8
通讯作者：
Paszat LF
中科院分区：
文献类型：
--
作者：
Ten Haaf K;Tammemägi MC;Bondy SJ;van der Aalst CM;Gu S;McGregor SE;Nicholas G;de Koning HJ;Paszat LF
国家肺筛查试验（NLST）的结果表明，在试验环境中，对目前和以前的吸烟者进行计算机断层扫描（CT）肺癌筛查，每年进行三次筛查，具有成本效益。然而，在以人群为基础的环境中，如果筛查轮次超过3轮，其成本效益是不确定的。因此，本研究的目的是评估加拿大安大略地区人群中肺癌筛查的成本效益，并评估筛查合格标准的影响。本研究使用了由各种数据源提供信息的微观模拟建模，包括安大略健康保险计划（OHIP）、安大略癌症登记处、吸烟行为调查和NLST。1940年至1969年出生的人，从第三方医疗保健支付者的角度进行了终身研究。从2015年开始，对576种CT筛查方案进行了检查，这些方案因开始和结束筛查的年龄、吸烟资格标准和筛查间隔而异。检查的结果指标包括避免的肺癌死亡，增加的生命年，筛查的百分比，成本（2015年加元）和过度诊断。基础病例分析的结果表明，每年一次的筛查比两年一次的筛查更具成本效益。在资格标准要求少至20包年的设想方案中，占主导地位的是要求更多累积包年数的设想方案。一般来说，应用严格的吸烟资格标准（即，需要更高水平的累积吸烟暴露）比吸烟资格标准不太严格的方案更具成本效益，获得的生命年差异不大。对吸烟≥ 40包-年且目前吸烟或戒烟≤ 10年的55 - 75岁人群进行年度筛查，产生的增量成本效益比为41，136加元（2015年5月1日为33,825美元，每增加生命年（与吸烟≥ 40包-年且目前吸烟或戒烟≤ 10年的60 - 75岁人群的年度筛查相比），这被认为是最佳的成本效益阈值为50,000加元（41,114美元，2015年5月1日）。如果假设可归因成本降低或增加50%，则该方案的增量成本效益比估计分别为38，240美元（2015年5月1日为31，444美元）或48，525美元（2015年5月1日为39，901美元）。如果假设CT检查的成本降低或增加50%，则该方案的增量成本-效果比估计分别为28，630美元（2015年5月1日为23，542美元）或73，507美元（2015年5月1日为60，443美元）。这一场景将筛选9.56%（499，261人）（曾经吸烟者和从不吸烟者）至少一次，这将需要4，788，523次CT检查，并将总人口的肺癌死亡率降低9.05%（预防13，108例肺癌死亡），而12.53%的筛查发现的癌症将被过度诊断（4，282例过度诊断病例）。敏感性分析表明，总体结果是最敏感的变化，CT检查费用。分析中未纳入生活质量，随访程序的假设基于NLST的数据，可能无法推广到基于人群的环境。在以人群为基础的环境中，采用严格的吸烟资格标准进行肺癌筛查可能具有成本效益。在对加拿大安大略人口的微观模拟模型分析中，Kevin ten Haaf及其同事比较了576种不同的肺癌筛查政策，这些政策具有不同的筛查频率和资格标准。在美国，肺癌筛查被推荐用于在过去15年内戒烟的当前和以前的吸烟者，年龄在55岁至80岁之间，吸烟至少30包-年;其他国家正在研究实施肺癌筛查政策的可行性。尽管许多组织建议进行肺癌筛查，但肺癌筛查的成本效益尚不确定;人们对实施肺癌筛查的潜在成本表示担忧。过去评估肺癌筛查成本效益的研究得出了不确定的结果。然而，这些研究考虑了有限数量的筛查政策，提供了有限的信息，不同的筛查政策特征如何影响肺癌筛查的成本效益。本研究探讨了不同的筛查政策特征，如筛查开始和停止年龄，筛查间隔，以及不同的吸烟史合格标准，如何影响肺癌筛查的性能和成本效益。一个微观模拟模型被用来分析576个不同的肺癌筛查政策之间出生的人在1940年和1969年在加拿大安大略。研究发现，要求严格的吸烟史资格标准（即，要求较高的累积吸烟暴露水平）比不太严格的吸烟史资格标准更具成本效益。将筛查限制在有大量（过去）吸烟史的个体可能会使肺癌筛查以具有成本效益的方式实施。与最初的预期相反，每年一次的筛查比两年一次的筛查更具成本效益。
The 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. This 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 overdiagnosed (4,282 overdiagnosed cases). Sensitivity analyses indicated that the overall results were most sensitive to variations in CT examination costs. Quality of life was not incorporated in the analyses, and assumptions for follow-up procedures were based on data from the NLST, which may not be generalizable to a population-based setting. Lung cancer screening with stringent smoking eligibility criteria can be cost-effective in a population-based setting. In a microsimulation modelling analysis of a population in Ontario, Canada, Kevin ten Haaf and colleagues compare 576 different lung cancer screening policies with different screening frequencies and eligibility criteria. In the US, lung cancer screening is recommended for current and former smokers who have quit within the past 15 y, aged 55 through 80 who smoked at least 30 pack-years; other countries are investigating the feasibility of implementing lung cancer screening policies. Despite lung cancer screening being recommended by a number of organizations, the cost-effectiveness of lung cancer screening is uncertain; concerns have been raised on the potential costs of implementing lung cancer screening. Past studies that evaluated the cost-effectiveness of lung cancer screening yielded inconclusive results. However, these studies considered limited numbers of screening policies, providing limited information on how different screening policy characteristics affect the cost-effectiveness of lung cancer screening. This study investigated how different screening policy characteristics, such as screening starting and stopping ages, screening interval, and different smoking history eligibility criteria, influence the performance and cost-effectiveness of lung cancer screening. A microsimulation model was used to analyze 576 different lung cancer screening policies for persons born between 1940 and 1969 in Ontario, Canada. The study found that requiring stringent smoking history eligibility criteria (i.e., requiring higher levels of accumulated smoking exposure) was more cost-effective than less stringent smoking history eligibility criteria. Limiting screening to individuals with substantial (past) smoking histories may allow lung cancer screening to be implemented in a cost-effective manner. In contrast to initial expectations, annual screening is suggested to be more cost-effective than biennial screening.