Lung, cancer screening with helical computed tomography in older adult smokers - A decision and cost-effectiveness analysis
Lung, cancer screening with helical computed tomography in older adult smokers - A decision and cost-effectiveness analysis
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DOI：
10.1001/jama.289.3.313
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发表时间：
2003-01-15
影响因子：
120.7
通讯作者：
Powe, NR
中科院分区：
文献类型：
--
作者：
Mahadevia, PJ;Fleisher, LA;Powe, NR
背景在直接面向消费者营销的鼓励下，吸烟者和他们的医生正在考虑使用一种有前途但未经证实的成像程序螺旋计算机断层扫描（CT）进行肺癌筛查。目的评估螺旋CT在各种有效性情况下进行肺癌筛查的潜在益处、危害和成本效益。设计、设置和人群使用计算机模拟模型，我们比较了每年螺旋CT筛查与不筛查100000例年龄60岁，其中55%为男性的当前、戒烟和既往重度吸烟者的假设队列。我们通过改变肺癌的临床分期分布来模拟疗效，这样筛查组的晚期癌症比未筛查组少，局部癌症比未筛查组多（即分期转移）。我们的模型纳入了已知的偏见，如前置时间，长度和过度诊断bias.Main结果Measures筛查程序我们衡量的好处，通过比较肺癌特异性死亡的绝对和相对差异。我们通过每10万人中假阳性侵入性检查或手术的数量以及每质量调整生命年（QALY）的增量成本效益来衡量危害。目前的重度吸烟者队列的肺癌死亡人数减少了553人，（肺癌特异性死亡率降低13%）和每10万人1186例假阳性侵入性手术。目前吸烟者的增量成本效益为116300美元/QALY。对于戒烟者和前吸烟者，每增加一个QALY的增量成本-效果分别为558600美元和2322700美元。除了阶段转移的程度，最具影响力的参数是坚持筛查，筛查第一年的长度或过度诊断偏倚的程度，筛查发现局部肺癌的人的生活质量，螺旋CT的成本，以及对不确定的结节诊断的焦虑。在单因素敏感性分析中，这些参数均不足以使任何队列的筛选具有高度成本效益。在多因素敏感性分析，一个程序筛选当前吸烟者是42 500美元每QALY获得的，如果非常有利的估计被用于所有的有影响力的参数同时。结论即使疗效最终被证明，筛选必须克服多个额外的障碍是非常具有成本效益的。鉴于目前的不确定性的好处，从侵入性测试的危害，并与筛查相关的高成本，直接向消费者销售螺旋CT是不可取的。
Context Encouraged by direct-to-consumer marketing, smokers and-their physicians are contemplating lung cancer screening with a promising but unproven imaging procedure, helical computed tomography (CT).Objective To estimate the potential benefits, harms, and cost-effectiveness of lung cancer screening with helical CT in various efficacy scenarios.Design, Setting, and Population Using a computer-simulated model, we compared annual helical CT screening to no screening for hypothetical cohorts of 100000 current, quitting, and former heavy smokers, aged 60 years, of whom 55% were men. We simulated efficacy by changing the clinical stage distribution of lung cancers so that the screened group would have fewer advanced-stage cancers and more localized-stage cancers than the nonscreened group (ie, a stage shift). Our model incorporated known biases in screening programs such as lead time, length, and overdiagnosis bias.Main Outcome Measures We measured the benefits of screening by comparing the absolute and relative difference in lung cancer-specific deaths. We measured harms by the number of false-positive invasive tests or surgeries per 100000 and incremental cost-effectiveness in US dollars per quality-adjusted life-year (QALY) gained.Results Over a 20-year period, assuming a 50% stage shift, the current heavy smoker cohort had 553 fewer lung cancer deaths (13% lung cancer-specific mortality reduction) and 1186 false-positive invasive procedures per 100000 persons. The incremental cost-effectiveness for current smokers was $116300 per QALY gained. For quitting and former smokers, the incremental cost-effectiveness was $558600 and $2322700 per QALY gained, respectively. Other than the degree of stage shift, the most influentia parameters were adherence to screening, degree of length or overdiagnosis bias in the first year of screening, quality of life of persons with screen-detected localized lung cancers, cost of helical CT, and anxiety about indeterminate nodule diagnoses. In 1-way sensitivity analyses, none of these parameters was sufficient to make screening highly cost-effective for any of the cohorts. In multiway sensitivity analyses, a program screening current smokers was $42 500 per QALY gained if extremely favorable estimates were used for all of the influential parameters simultaneously.Conclusion Even if efficacy is eventually proven, screening must overcome multiple additional barriers to be highly cost-effective. Given the current uncertainty of benefits, the harms from invasive testing, and the high costs associated with screening, direct-to-consumer marketing of helical CT is not advisable.