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Criss SD, Mooradian MJ, Sheehan DF, Zubiri L, Lumish MA, Gainor JF, Reynolds KL, Kong CY. Cost-effectiveness and Budgetary Consequence Analysis of Durvalumab Consolidation Therapy vs No Consolidation Therapy After Chemoradiotherapy in Stage III Non-Small Cell Lung Cancer in the Context of the US Health Care System. JAMA Oncol 2019; 5:358-365. [PMID: 30543349 DOI: 10.1001/jamaoncol.2018.5449] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance In early 2018, durvalumab became the first immunotherapy to be approved for adjuvant treatment of patients with unresectable stage III non-small cell lung cancer (NSCLC) whose cancer has not progressed after definitive chemoradiotherapy. However, the cost-effectiveness and potential economic implications of using this high-priced therapy in this indication are unknown to date. Objective To explore the cost-effectiveness and potential budgetary consequences of durvalumab consolidation therapy vs no consolidation therapy after chemoradiotherapy in stage III NSCLC in the context of the US health care system. Design, Setting, and Participants A decision analytic microsimulation model was developed in an academic medical setting to compare the following 2 postchemoradiotherapy strategies: all patients receive no consolidation therapy until progression vs all patients receive durvalumab consolidation therapy until progression or for a maximum of 1 year. The potential budgetary consequence was calculated by applying the proportion of patients with NSCLC who were diagnosed in stage III and received chemoradiotherapy to the projected number of annual new cases for 2018 to 2022 to find total eligible patients and then multiplied by the mean difference in annual cost between the strategies over this 5-year period. Simulated conditions were matched to those of the PACIFIC phase 3 randomized clinical trial and reasonable treatment strategies for metastatic NSCLC. All simulated patients begin disease free after having received radical treatment with chemoradiotherapy and are followed up as they progress to metastatic disease first-line treatment, metastatic disease second-line treatment, end-stage progressive disease, and death. Main Outcomes and Measures The main outcome of this study was the incremental cost-effectiveness ratio of durvalumab consolidation therapy vs no consolidation therapy, given as aggregate cost of treatment per quality-adjusted life-year gained. Results Among 2 million simulated patients, durvalumab consolidation therapy was cost-effective compared with no consolidation therapy at a $100 000 per quality-adjusted life-year willingness-to-pay threshold, with an estimated incremental cost-effectiveness ratio of $67 421 per quality-adjusted life-year, and would contribute an additional $768 million to national cancer spending in year 1. The annual budgetary consequence would then decrease to $241 million in year 5. Conclusions and Relevance Durvalumab consolidation therapy represents an indication where expensive immunotherapies can be cost-effective. Treating with immunotherapy earlier in the course of cancer progression can provide significant value, despite having a substantial budgetary consequence.
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Affiliation(s)
- Steven D Criss
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Meghan J Mooradian
- Massachusetts General Hospital Cancer Center, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Leyre Zubiri
- Massachusetts General Hospital Cancer Center, Boston.,Harvard Medical School, Boston, Massachusetts
| | | | - Justin F Gainor
- Massachusetts General Hospital Cancer Center, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Kerry L Reynolds
- Massachusetts General Hospital Cancer Center, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
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Criss SD, Cao P, Bastani M, Ten Haaf K, Chen Y, Sheehan DF, Blom EF, Toumazis I, Jeon J, de Koning HJ, Plevritis SK, Meza R, Kong CY. Cost-Effectiveness Analysis of Lung Cancer Screening in the United States: A Comparative Modeling Study. Ann Intern Med 2019; 171:796-804. [PMID: 31683314 DOI: 10.7326/m19-0322] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Recommendations vary regarding the maximum age at which to stop lung cancer screening: 80 years according to the U.S. Preventive Services Task Force (USPSTF), 77 years according to the Centers for Medicare & Medicaid Services (CMS), and 74 years according to the National Lung Screening Trial (NLST). OBJECTIVE To compare the cost-effectiveness of different stopping ages for lung cancer screening. DESIGN By using shared inputs for smoking behavior, costs, and quality of life, 4 independently developed microsimulation models evaluated the health and cost outcomes of annual lung cancer screening with low-dose computed tomography (LDCT). DATA SOURCES The NLST; Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial; SEER (Surveillance, Epidemiology, and End Results) program; Nurses' Health Study and Health Professionals Follow-up Study; and U.S. Smoking History Generator. TARGET POPULATION Current, former, and never-smokers aged 45 years from the 1960 U.S. birth cohort. TIME HORIZON 45 years. PERSPECTIVE Health care sector. INTERVENTION Annual LDCT according to NLST, CMS, and USPSTF criteria. OUTCOME MEASURES Incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). RESULTS OF BASE-CASE ANALYSIS The 4 models showed that the NLST, CMS, and USPSTF screening strategies were cost-effective, with ICERs averaging $49 200, $68 600, and $96 700 per QALY, respectively. Increasing the age at which to stop screening resulted in a greater reduction in mortality but also led to higher costs and overdiagnosis rates. RESULTS OF SENSITIVITY ANALYSIS Probabilistic sensitivity analysis showed that the NLST and CMS strategies had higher probabilities of being cost-effective (98% and 77%, respectively) than the USPSTF strategy (52%). LIMITATION Scenarios assumed 100% screening adherence, and models extrapolated beyond clinical trial data. CONCLUSION All 3 sets of lung cancer screening criteria represent cost-effective programs. Despite underlying uncertainty, the NLST and CMS screening strategies have high probabilities of being cost-effective. PRIMARY FUNDING SOURCE CISNET (Cancer Intervention and Surveillance Modeling Network) Lung Group, National Cancer Institute.
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Affiliation(s)
- Steven D Criss
- Massachusetts General Hospital, Boston, Massachusetts (S.D.C., Y.C.)
| | - Pianpian Cao
- University of Michigan, Ann Arbor, Michigan (P.C., J.J., R.M.)
| | - Mehrad Bastani
- Stanford University School of Medicine, Stanford, California (M.B., I.T., S.K.P.)
| | - Kevin Ten Haaf
- Erasmus University Medical Center, Rotterdam, the Netherlands (K.T., E.F.B., H.J.D.)
| | - Yufan Chen
- Massachusetts General Hospital, Boston, Massachusetts (S.D.C., Y.C.)
| | - Deirdre F Sheehan
- Massachusetts General Hospital, Boston, Massachusetts, and Broad Institute, Cambridge, Massachusetts (D.F.S.)
| | - Erik F Blom
- Erasmus University Medical Center, Rotterdam, the Netherlands (K.T., E.F.B., H.J.D.)
| | - Iakovos Toumazis
- Stanford University School of Medicine, Stanford, California (M.B., I.T., S.K.P.)
| | - Jihyoun Jeon
- University of Michigan, Ann Arbor, Michigan (P.C., J.J., R.M.)
| | - Harry J de Koning
- Erasmus University Medical Center, Rotterdam, the Netherlands (K.T., E.F.B., H.J.D.)
| | - Sylvia K Plevritis
- Stanford University School of Medicine, Stanford, California (M.B., I.T., S.K.P.)
| | - Rafael Meza
- University of Michigan, Ann Arbor, Michigan (P.C., J.J., R.M.)
| | - Chung Yin Kong
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (C.Y.K.)
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Tramontano AC, Chen Y, Watson TR, Eckel A, Sheehan DF, Peters MLB, Pandharipande PV, Hur C, Kong CY. Pancreatic cancer treatment costs, including patient liability, by phase of care and treatment modality, 2000-2013. Medicine (Baltimore) 2019; 98:e18082. [PMID: 31804317 PMCID: PMC6919520 DOI: 10.1097/md.0000000000018082] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Our study provides phase-specific cost estimates for pancreatic cancer based on stage and treatment. We compare treatment costs between the different phases and within the stage and treatment modality subgroups. METHODS Our cohort included 20,917 pancreatic cancer patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed between 2000 and 2011. We allocated costs into four phases of care-staging (or surgery), initial, continuing, and terminal- and calculated the total, cancer-attributable, and patient-liability costs in 2018 US dollars. We fit linear regression models using log transformation to determine whether costs were predicted by age and calendar year. RESULTS Monthly cost estimates were high during the staging and surgery phases, decreased over the initial and continuing phases, and increased during the three-month terminal phase. Overall, the linear regression models showed that cancer-attributable costs either remained stable or increased by year, and either were unaffected by age or decreased with older age; continuing phase costs for stage II patients increased with age. CONCLUSIONS Our estimates demonstrate that pancreatic cancer costs can vary widely by stage and treatment received. These cost estimates can serve as an important baseline foundation to guide resource allocation for cancer care and research in the future.
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Affiliation(s)
| | - Yufan Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Tina R. Watson
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Deirdre F. Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Mary Linton B. Peters
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, MA
- Harvard Medical School, Boston, MA
| | - Pari V. Pandharipande
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Chin Hur
- Columbia University Medical Center, New York City, NY
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Chen Y, Watson TR, Criss SD, Eckel A, Palazzo L, Sheehan DF, Kong CY. A simulation study of the effect of lung cancer screening in China, Japan, Singapore, and South Korea. PLoS One 2019; 14:e0220610. [PMID: 31361789 PMCID: PMC6667161 DOI: 10.1371/journal.pone.0220610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/21/2019] [Indexed: 12/24/2022] Open
Abstract
More than 50% of the world's lung cancer cases occur in Asia and more than 20% of cancer deaths in Asia are attributable to lung cancer. The U.S. National Lung Screening Trial has shown that lung cancer screening with computed tomography (CT) can reduce lung cancer deaths. Using the Lung Cancer Policy Model-Asia (LCPM-Asia), we estimated the potential mortality reduction achievable through the implementation of CT-based lung cancer screening in China, Japan, Singapore, and South Korea. The LCPM-Asia was calibrated to the smoking prevalence of each of the aforementioned countries based on published national surveys and to lung cancer mortality rates from the World Health Organization. The calibrated LCPM-Asia was then used to simulate lung cancer deaths under screening and no-screening scenarios for the four countries. Using screening eligibility criteria recommended by the U.S. Centers for Medicare & Medicaid Services (CMS), which are based on age and smoking history, we estimated the lung cancer mortality reduction from screening through year 2040. By 2040, lung cancer screening would result in 91,362 life-years gained and 4.74% mortality reduction in South Korea; 290,325 life-years gained and 4.33% mortality reduction in Japan; 3,014,215 life-years gained and 4.22% mortality reduction in China; and 8,118 life-years gained and 3.76% mortality reduction in Singapore. As for mortality reduction by smoker type, current smokers would have the greatest mortality reduction in each country, ranging from 5.56% in Japan to 6.86% in Singapore. Among the four countries, lung cancer screening under CMS eligibility criteria was most effective in South Korea and least effective in Singapore. Singapore's low smoking prevalence and South Korea's aging population and higher smoking prevalence may partially explain the discrepancy in effectiveness. CT screening was shown to be promising as a means of reducing lung cancer mortality in the four countries.
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Affiliation(s)
- Yufan Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Tina R. Watson
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Steven D. Criss
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lauren Palazzo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Deirdre F. Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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Criss SD, Weaver DT, Sheehan DF, Lee RJ, Pandharipande PV, Kong CY. Effect of PD-L1 testing on the cost-effectiveness and budget impact of pembrolizumab for advanced urothelial carcinoma of the bladder in the United States. Urol Oncol 2019; 37:180.e11-180.e18. [DOI: 10.1016/j.urolonc.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 01/07/2023]
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Palazzo LL, Sheehan DF, Tramontano AC, Kong CY. Disparities and Trends in Genetic Testing and Erlotinib Treatment among Metastatic Non-Small Cell Lung Cancer Patients. Cancer Epidemiol Biomarkers Prev 2019; 28:926-934. [PMID: 30787053 DOI: 10.1158/1055-9965.epi-18-0917] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/13/2018] [Accepted: 02/14/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite reports of socioeconomic disparities in rates of genetic testing and targeted therapy treatment for metastatic non-small cell lung cancer (NSCLC), little is known about whether such disparities are changing over time. METHODS We performed a retrospective analysis to identify disparities and trends in genetic testing and treatment with erlotinib. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified 9,900 patients with stage IV NSCLC diagnosed in 2007 to 2011 at age 65 or older. We performed logistic regression analyses to identify patient factors associated with odds of receiving a genetic test and erlotinib treatment, and to assess trends in these differences with respect to diagnosis year. RESULTS Patients were more likely to receive genetic testing if they were under age 75 at diagnosis [odds ratio (OR), 1.55] independent of comorbidity level, and this age-based gap showed a decrease over time (OR, 0.93). For untested patients, erlotinib treatment was associated with race (OR, 0.58, black vs. white; OR, 2.45, Asian vs. white), and was more likely among female patients (OR, 1.45); for tested patients, erlotinib treatment was less likely among low-income patients (OR, 0.32). Most of these associations persisted or increased in magnitude. CONCLUSIONS Race and sex are associated with rates of erlotinib treatment for patients who did not receive genetic testing, and low-income status is associated with treatment rates for those who did receive testing. The racial disparity remained stable over time, while the income-based disparity grew larger. IMPACT Attention to reducing disparities is needed as precision cancer treatments continue to be developed.
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Affiliation(s)
- Lauren L Palazzo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts
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Sheehan DF, Criss SD, Chen Y, Eckel A, Palazzo L, Tramontano AC, Hur C, Cipriano LE, Kong CY. Lung cancer costs by treatment strategy and phase of care among patients enrolled in Medicare. Cancer Med 2018; 8:94-103. [PMID: 30575329 PMCID: PMC6346221 DOI: 10.1002/cam4.1896] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/01/2018] [Accepted: 11/06/2018] [Indexed: 12/16/2022] Open
Abstract
Background We studied trends in lung cancer treatment cost over time by phase of care, treatment strategy, age, stage at diagnosis, and histology. Methods Using the Surveillance, Epidemiology, and End Results (SEER)‐Medicare database for years 1998‐2013, we allocated total and patient‐liability costs into the following phases of care for 145 988 lung cancer patients: prediagnosis, staging, surgery, initial, continuing, and terminal. Patients served as self‐controls to determine cancer‐attributable costs based on individual precancer diagnosis healthcare costs. We fit linear regression models to determine cost by age and calendar year for each stage at diagnosis, histology, and treatment strategy and presented all costs in 2017 US dollars. Results Monthly healthcare costs prior to lung cancer diagnosis were $861 for a 70 years old in 2017 and rose by an average of $17 per year (P < 0.001). Surgery in 2017 cost $30 096, decreasing by $257 per year (P = 0.007). Chemotherapy and radiation costs remained stable or increased for most stage and histology groups, ranging from $4242 to $8287 per month during the initial six months of care. Costs during the final six months of life decreased for those who died of lung cancer or other causes. Conclusions Cost‐effectiveness analyses of lung cancer control interventions in the United States have been using outdated and incomplete treatment cost estimates. Our cost estimates enable updated cost‐effectiveness analyses to determine the benefit of lung cancer control from a health economics point of view.
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Affiliation(s)
- Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven D Criss
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Yufan Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Lauren Palazzo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts.,Department of Radiology, Harvard Medical School, Boston, Massachusetts
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Criss SD, Sheehan DF, Palazzo L, Kong CY. Population impact of lung cancer screening in the United States: Projections from a microsimulation model. PLoS Med 2018; 15:e1002506. [PMID: 29415013 PMCID: PMC5802442 DOI: 10.1371/journal.pmed.1002506] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/12/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Previous simulation studies estimating the impacts of lung cancer screening have ignored the changes in smoking prevalence over time in the United States. Our primary rationale was to perform, to our knowledge, the first simulation study that estimates the health outcomes of lung cancer screening with explicit modeling of smoking trends for the whole US population. METHODS/FINDINGS Utilizing a well-validated microsimulation model, we estimated the benefits and harms of an annual low-dose computed tomography screening scenario with a realistic screening adherence rate versus a no-screening scenario for the US population from 2016-2030. The Centers for Medicare and Medicaid Services (CMS) eligibility criteria were applied: age 55-77 years at time of screening, history of at least 30 pack-years of smoking, and current smoker or former smoker with fewer than 15 years since quitting. In the screened population, cumulative mortality reduction was projected to reach 16.98% (95% CI 16.90%-17.07%). Cumulative mortality reduction was estimated to be 3.52% (95% CI 3.50%-3.53%) for the overall study population, with annual mortality reduction peaking at 4.38% (95% CI 4.36%-4.41%) in 2021 and falling to 3.53% (95% CI 3.50%-3.56%) by 2030. Lung cancer screening would save a projected 148,484 life-years (95% CI 147,429-149,540) across the total population through 2030. There were estimated to be 9,054 (95% CI 9,011-9,098) overdiagnosed cases among the 252,429 (95% CI 251,208-253,649) screen-detected lung cancer diagnoses, yielding an overdiagnosis rate of 3.59%. The limitations of our study are that we do not explicitly model race or socioeconomic status and our model was calibrated to data from studies performed in academic centers, both of which may impact the generalizability of our results. We also exclusively model the effects of the CMS guidelines for lung cancer screening and not any other screening strategies. CONCLUSIONS The mortality reduction and life-years gained estimated by this study are lower than those of single birth cohort studies. Single cohort studies neglect the changing dynamics of smoking behavior across generations, whereas this study reflects the trend of decreasing smoking prevalence since the 1960s. Maximum benefit could be derived from lung cancer screening through 2021; in later years, mortality reduction due to screening will decline. If a comprehensive screening program is not implemented in the near future, the opportunity to achieve these benefits will have passed.
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Affiliation(s)
- Steven D. Criss
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Deirdre F. Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lauren Palazzo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Sheehan DF, Criss SD, Gazelle GS, Pandharipande PV, Kong CY. Evaluating lung cancer screening in China: Implications for eligibility criteria design from a microsimulation modeling approach. PLoS One 2017; 12:e0173119. [PMID: 28273181 PMCID: PMC5342219 DOI: 10.1371/journal.pone.0173119] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 02/15/2017] [Indexed: 11/18/2022] Open
Abstract
More than half of males in China are current smokers and evidence from western countries tells us that an unprecedented number of smoking-attributable deaths will occur as the Chinese population ages. We used the China Lung Cancer Policy Model (LCPM) to simulate effects of computed tomography (CT)-based lung cancer screening in China, comparing the impact of a screening guideline published in 2015 by a Chinese expert group to a version developed for the United States by the U.S. Centers for Medicare & Medicaid Services (CMS). The China LCPM, built using an existing lung cancer microsimulation model, can project population outcomes associated with interventions for smoking-related diseases. After calibrating the model to published Chinese smoking prevalence and lung cancer mortality rates, we simulated screening from 2016 to 2050 based on eligibility criteria from the CMS and Chinese guidelines, which differ by age to begin and end screening, pack-years smoked, and years since quitting. Outcomes included number of screens, mortality reduction, and life-years saved for each strategy. We projected that in the absence of screening, 14.98 million lung cancer deaths would occur between 2016 and 2050. Screening with the CMS guideline would prevent 0.72 million deaths and 5.8 million life-years lost, resulting in 6.58% and 1.97% mortality reduction in males and females, respectively. Screening with the Chinese guideline would prevent 0.74 million deaths and 6.6 million life-years lost, resulting in 6.30% and 2.79% mortality reduction in males and females, respectively. Through 2050, 1.43 billion screens would be required using the Chinese screening strategy, compared to 988 million screens using the CMS guideline. In conclusion, CT-based lung cancer screening implemented in 2016 and based on the Chinese screening guideline would prevent about 20,000 (2.9%) more lung cancer deaths through 2050, but would require about 445 million (44.7%) more screens than the CMS guideline.
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Affiliation(s)
- Deirdre F. Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Steven D. Criss
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - G. Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Pari V. Pandharipande
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Kong CY, Sheehan DF, McMahon PM, Gazelle GS, Pandharipande P. Combined Biomarker and Computed Tomography Screening Strategies for Lung Cancer: Projections of Health and Economic Tradeoffs in the US Population. MDM Policy Pract 2016; 1. [PMID: 30148212 PMCID: PMC6116540 DOI: 10.1177/2381468316643968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Lung cancer screening with computed tomography (CT) of
individuals who meet certain age and smoking history criteria is the current
standard-of-care. Methods: Using a published simulation model, we
compared outcomes associated with seven biomarker + CT screening strategies to
CT screening alone using Centers for Medicare & Medicaid Services
eligibility criteria. We assumed that the biomarker had conditionally
independent performance; was used for first-line screening in some, or all,
individuals screened; and could be extended to Centers for Medicare &
Medicaid Services–ineligible smokers. Strategies differed by inclusion criteria
(e.g., pack-years) and proportion of individuals for whom CT remained the
first-line test. Each model run simulated a combined cohort of one million men
and one million women born in 1950. Primary outcomes were cancer-specific
mortality reduction and screening costs; biomarker costs were measured relative
to CT. Efficiency frontiers identified optimal health and economic tradeoffs.
Sensitivity analysis evaluated the stability of results. Results:
Standard-of-care screening yielded an 8.3% cancer-specific mortality reduction
in the simulated US population (screened + unscreened individuals). For a
biomarker test with 75% sensitivity and 95% specificity, mortality reductions
across biomarker + CT strategies ranged from 7.0% to 23.9%. If the biomarker’s
cost was >0.86× that of CT, standard-of-care screening remained on the
efficiency frontier, indicating that health and economic tradeoffs were equally
(or more) efficient relative to all biomarker + CT strategies. Biomarker + CT
strategy costs were principally driven by biomarker specificity; mortality
reduction was driven by sensitivity. Conclusion: Combined biomarker
+ CT strategies have the potential to improve future lung cancer screening
effectiveness in the United States and achieve economic efficiency that is
greater than the current standard-of-care.
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Affiliation(s)
- Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pamela M McMahon
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Pari Pandharipande
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Tramontano AC, Sheehan DF, McMahon PM, Dowling EC, Holford TR, Ryczak K, Lesko SM, Levy DT, Kong CY. Evaluating the impacts of screening and smoking cessation programmes on lung cancer in a high-burden region of the USA: a simulation modelling study. BMJ Open 2016; 6:e010227. [PMID: 26928026 PMCID: PMC4780060 DOI: 10.1136/bmjopen-2015-010227] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 02/02/2016] [Accepted: 02/09/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE While the US Preventive Services Task Force has issued recommendations for lung cancer screening, its effectiveness at reducing lung cancer burden may vary at local levels due to regional variations in smoking behaviour. Our objective was to use an existing model to determine the impacts of lung cancer screening alone or in addition to increased smoking cessation in a US region with a relatively high smoking prevalence and lung cancer incidence. SETTING Computer-based simulation model. PARTICIPANTS Simulated population of individuals 55 and older based on smoking prevalence and census data from Northeast Pennsylvania. INTERVENTIONS Hypothetical lung cancer control from 2014 to 2050 through (1) screening with CT, (2) intensified smoking cessation or (3) a combination strategy. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes were lung cancer mortality rates. Secondary outcomes included number of people eligible for screening and number of radiation-induced lung cancers. RESULTS Combining lung cancer screening with increased smoking cessation would yield an estimated 8.1% reduction in cumulative lung cancer mortality by 2050. Our model estimated that the number of screening-eligible individuals would progressively decrease over time, indicating declining benefit of a screening-only programme. Lung cancer screening achieved a greater mortality reduction in earlier years, but was later surpassed by smoking cessation. CONCLUSIONS Combining smoking cessation programmes with lung cancer screening would provide the most benefit to a population, especially considering the growing proportion of patients ineligible for screening based on current recommendations.
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Affiliation(s)
- Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pamela M McMahon
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Emily C Dowling
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Theodore R Holford
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Karen Ryczak
- Northeast Regional Cancer Institute, Scranton, Pennsylvania, USA
| | - Samuel M Lesko
- Northeast Regional Cancer Institute, Scranton, Pennsylvania, USA
| | - David T Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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