The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: Systematic reviews

Department of Public Health, University of Aberdeen, UK.
Health technology assessment (Winchester, England) (Impact Factor: 5.03). 02/2006; 10(3):iii-iv, ix-x, 1-90. DOI: 10.3310/hta10030
Source: PubMed


The aim of this review is to examine the clinical and cost-effectiveness of screening for lung cancer using computed tomography (CT) to assist policy making and to clarify research needs.
Electronic databases and Internet resources.
A systematic review was undertaken and selected studies were assessed using the checklists and methods described in NHS Centre for Reviews and Dissemination (CRD) Report 4. Separate narrative summaries were performed for clinical effectiveness and cost-effectiveness. Cost-effectiveness analysis resulting in a cost per quality-adjusted life-year was not feasible, therefore the main elements of such an appraisal were summarised and the key issues relating to the existing evidence base were discussed.
Twelve studies of CT screening for lung cancer were identified, including two randomised controlled trials (RCTs) and ten studies of screening without comparator groups. The quality of reporting of these studies was variable, but the overall quality was adequate. The two RCTs were of short duration (1 year) and therefore there was currently no evidence that screening improves survival or reduces mortality. The proportion of people with abnormal CT findings varied widely between studies (5-51%). The prevalence of lung cancer detected was between 0.4% and 3.2% (number need to screen to detect one lung cancer = 31-249). Incidence rates of lung cancer were lower (0.1-1% per year). Detection of stage I and resectable tumours was high, 100% in some studies. Adverse events, as a result of investigation or surgery, or the screening process per se were poorly reported. Incidental findings of other abnormalities requiring medical follow-up were reported to be as high as 49%. Six full economic evaluations of population CT screening programmes for lung cancer were included in the review. The magnitude of cost-effectiveness ratios reported varied widely. None was set in the UK and generalisation was complicated by wide variation in the data used in different countries and a paucity of UK data for comparison. All six made the fundamental assumption that screening with CT for lung cancer reduced mortality. At the current time, there is no evidence to support that assumption. In the absence of evidence of health gains from screening for lung cancer, in terms of either quantity or quality of life, and faced with a range of uncertainties, from the frequency of abnormal screening findings within a population to the natural history of screening detected lung cancers, it is not feasible at the current time to develop accurately and meaningfully an economic argument for CT screening for lung cancer in the UK. For subgroups, in particular certain occupational groups, there is evidence of increased risk of lung cancer, but the role of screening has not been demonstrated by the current studies.
The accepted National Screening Committee criteria are not currently met, with no RCTs, no evidence to support clinical effectiveness and no evidence of cost-effectiveness. RCTs are needed to examine the effect of CT screening on mortality, either with whole-population screening or for particular subgroups; to determine the rate of positive screening and detected lung cancers. Research is also needed to understand better the natural history and epidemiology of screening-detected lung cancers, particularly small, well-differentiated adenocarcinomas; as well as the impacts on quality of life. Increased collection is needed of UK health service data regarding resource use and safety data for lung cancer management and services. Research is also needed into the feasibility and logistics of tracing people who have in the past worked in industry where there was exposure to lung carcinogens.

Download full-text


Available from: Corri Black, Jul 18, 2014
  • Source
    • "Model inputs. A major challenge in modelling the natural history of NSCLC is the requirement to understand the transition of patients in prediagnostic stages of disease, which cannot be informed by clinical trials (Black et al, 2006). Therefore, in the absence of observable data, model calibration techniques (Weinstein, 2006; Whyte et al, 2011), together with the elicitation of clinical knowledge, were used to estimate the unobservable transition probabilities. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Survival rates in lung cancer in England are significantly lower than in many similar countries. A range of Be Clear on Cancer (BCOC) campaigns have been conducted targeting lung cancer and found to improve the proportion of diagnoses at the early stage of disease. This paper considers the cost-effectiveness of such campaigns, evaluating the effect of both the regional and national BCOC campaigns on the stage distribution of non-small-cell lung cancer (NSCLC) at diagnosis. A natural history model of NSCLC was developed using incidence data, data elicited from clinical experts and model calibration techniques. This structure is used to consider the lifetime cost and quality-adjusted survival implications of the early awareness campaigns. Incremental cost-effectiveness ratios (ICERs) in terms of additional costs per quality-adjusted life-years (QALYs) gained are presented. Two scenario analyses were conducted to investigate the role of changes in the 'worried-well' population and the route of diagnosis that might occur as a result of the campaigns. The base-case theoretical model found the regional and national early awareness campaigns to be associated with QALY gains of 289 and 178 QALYs and ICERs of £13 660 and £18 173 per QALY gained, respectively. The scenarios found that increases in the 'worried-well' population may impact the cost-effectiveness conclusions. Subject to the available evidence, the analysis suggests that early awareness campaigns in lung cancer have the potential to be cost-effective. However, significant additional research is required to address many of the limitations of this study. In addition, the estimated natural history model presents previously unavailable estimates of the prevalence and rate of disease progression in the undiagnosed population.British Journal of Cancer advance online publication, 26 May 2015; doi:10.1038/bjc.2015.167
    British Journal of Cancer 05/2015; 113(1). DOI:10.1038/bjc.2015.167 · 4.84 Impact Factor
  • Source
    • "Results from the International Early Lung Cancer Action Project (I-ELCAP) demonstrating striking improvement in early stage detection of lung cancer by low-radiation-dose computed tomography (CT) screening (Henschke et al, 1999; Henschke et al, 2001) have sparked debate on the cost-effectiveness of a CT screening programme, with widely variant results reported (Marshall et al, 2001a; Marshall et al, 2001b; Chirikos et al, 2002; Mahadevia et al, 2003; Wisnivesky et al, 2003). In a systemic review published in January 2006 (Black et al, 2006), the authors conclude that many issues remain unresolved in the debate over the true costeffectiveness of lung cancer screening programmes. Attention to this issue has further escalated following the reported results of over 30 000 persons screened in the large collaborative I-ELCAP study, which concluded that annual spiral CT screening can detect lung cancer that is curable in most cases (Henschke et al, 2006a). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Our objective was to analyse the cost effectiveness of computed tomography (CT) screening for lung cancer in terms of the cost per long-term survivor, which has not been evaluated to date. Estimations were computed based on data from the Surveillance, Epidemiology, and End Results registries covering years 1999-2003. The design framework of our model allowed for the incorporation of multiple values taken from the epidemiological and clinical literature to be utilised for cost inputs, scope of patients screened, diagnostic staging, and survival percentages applied separately to two cohorts: age 40-79 and 60-79 years. This enabled the analysis of over 1400 scenarios, each containing a unique set of input values, for which the estimated cost per 5-year survivor (CP5YS) was compared between the symptom-detected and proactive screening approaches. Estimated CP5YS were higher for the symptom-detected approach in all 729 scenarios analysed for the cohort ages 60-79 years, ranging from approximately $5800 to $116,700 increased cost per 5-year survivor (CP5YS). For the cohort ages 40-79 years, 75% of the 729 scenarios analysed showed increased CP5YS for the symptom-detected approach ranging from $5700 to $110,000 increased CP5YS. Total costs and total 5-year survivors were higher for the proactive screening method for all scenarios analysed across both cohorts with increases ranging from 50-256% and 98-309%, respectively. The predicted increase in long-term survival with CT screening and the potential for better utilisation of health-care dollars in terms of CP5YS, particularly when screening patients over the age of 60 years, are critically important considerations in directing effective future lung cancer management strategy.
    British Journal of Cancer 09/2009; 101(6):882-96. DOI:10.1038/sj.bjc.6605253 · 4.84 Impact Factor
  • Source
    • "The state of evidence for individually requested screening tests varies greatly, from screening examinations with no trial data (as for whole-body screening CT) to examinations for which trials have established that screening detects disease earlier in its course but have not yet concluded that screening improves population outcomes (as for lung CT screening in smokers) (Black et al. 2006; Henschke et al. 2006). Most CT screening examinations are not considered by professional societies, governmental bodies, or insurers to have sufficient levels of evidence of population benefit to recommend population screening. "
    [Show abstract] [Hide abstract]
    ABSTRACT: During the past decade, screening tests using computed tomography (CT) have disseminated into practice and been marketed to patients despite neither conclusive evidence nor professional agreement about their efficacy and cost-effectiveness at the population level. This phenomenon raises questions about physicians' professional roles and responsibilities within the setting of medical innovation, as well as the appropriate scope of patient autonomy and access to unproven screening technology. This article explores how physicians ought to respond when new screening examinations that lack conclusive evidence of overall population benefit emerge in the marketplace and are requested by individual patients. To this end, the article considers the nature of evidence and how it influences decision-making for screening at both the public policy and individual patient levels. We distinguish medical and ethical differences between screening recommended for a population and screening considered on an individual patient basis. Finally, we discuss specific cases to explore how evidence, patient risk factors and preferences, and physician judgment ought to balance when making individual patient screening decisions.
    The American Journal of Bioethics 05/2009; 9(4):3-14. DOI:10.1080/15265160902790583 · 5.29 Impact Factor
Show more