The Cost-Effectiveness of High-Risk Lung Cancer Screening and Drivers of Program Efficiency

Sonya Cressman, Stuart J. Peacock, Martin C. Tammemägi, William K. Evans, Natasha B. Leighl, John R. Goffin, Alain Tremblay, Geoffrey Liu, Daria Manos, Paul MacEachern, Rick Bhatia, Serge Puksa, Garth Nicholas, Annette McWilliams, John R. Mayo, John Yee, John C. English, Reka Pataky, Emily McPherson, Sukhinder Atkar-Khattra, Michael R. Johnston, Heidi Schmidt, Frances A. Shepherd, Kam Soghrati, Kayvan Amjadi, Paul Burrowes, Christian Couture, Harmanjatinder S. Sekhon, Kazuhiro Yasufuku, Glenwood Goss, Diana N. Ionescu, David M. Hwang, Simon Martel, Don D. Sin, Wan C. Tan, Stefan Urbanski, Zhaolin Xu, Ming-Sound Tsao, Stephen Lam

Lung cancer risk prediction models have the potential to make programs more affordable; however, the economic evidence is limited. Participants in the National Lung Cancer Screening Trial (NLST) were retrospectively identified with the PLCOm2009 risk-prediction tool. The high-risk subgroup was assessed for lung cancer incidences and demographic character compared with the low-risk subgroup and the Pan-Canadian Early Detection of Lung Cancer Study (PanCan)-an observational study, that was high-risk selected in Canada. A comparison of high-risk screening versus standard care was made with a decision-analytic model, using data from the NLST with Canadian cost data from screening and treatment in the PanCan study. Probabilistic and deterministic sensitivity analyses were undertaken to assess uncertainty and identify drivers of program efficiency. Use of the PLCOm2009 risk prediction tool with a threshold set at 2% over 6 years would have reduced the number needed to screen in the NLST by 81%. High-risk screening participants in the NLST had more adverse demographic characteristics than the PanCan study. High-risk screening would cost $20,724 (2015 CAD) per quality-adjusted life year gained (QALY) and would be considered cost-effective at a willingness to pay threshold of $100,000/QALY with a probability of 0.62. Cost-effectiveness was driven primarily by non-lung cancer outcomes. Higher non-curative drug costs or current costs for immunotherapy and targeted therapies in the U.S. would render lung cancer screening a cost-saving intervention. Non-lung cancer outcomes drive screening efficiency in diverse, tobacco-exposed populations. Use of risk selection can reduce the budget impact and screening may even offer cost-savings if non-curative treatment costs continue to rise.