Cost-effectiveness of CT Screening in the National Lung Screening Trial

Published in: New England Journal of Medicine, v. 371, no. 19, Nov. 2014, p. 1793-1802

Posted on RAND.org on November 01, 2014

by William C. Black, Ilana F. Gareen, Samir S. Soneji, JoRean D. Sicks, Emmett B. Keeler, Denise R. Aberle, Arash Naeim, Timothy R. Church, Gerard A. Silvestri, Jeremy Gorelick, Constantine Gatsonis

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Research Question

  1. How cost effective was lung cancer screening with low-dose computed tomography (CT) in the National Lung Screening Trial?

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.

Key Findings

  • CT screening reduced death from lung cancer by 20% during the 6 year trial among heavy smokers age 50-74.
  • The cost was about $81,000/QALY gained.
  • If screening is extended to not-so-heavy smokers, its value falls dramatically, and radiation risks may outweigh screening gains.

Recommendation

CT lung cancer screening should target those most likely to benefit.

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