Cost of a 5-year lung cancer survivor: symptomatic tumour identification vs proactive computed tomography screening

Receipt of recommended surveillance with imaging in elderly survivors of early stage non-small cell lung cancer

PURPOSE

Early-stage lung cancer survivorsremain at high risk for recurrence or second cancers. We measured the rates and determinants of regular surveillance imaging in early-stage non-small cell lung cancer (NSCLC) survivors.

METHODS

Patients (diagnosed 2001-2011) with resected stage I and II NSCLC were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked database. Patients were censored at recurrence/second cancer diagnosis, loss to follow-up or death. Receipt of a scan during the surveillance periods of 7-18, 19-30, 31-42 and 43-60 months from date of surgery was assessed.

RESULTS

Of 10,680 survivors assessed during the 18-month surveillance period, 71% received imaging in first 18 months. Only 56% and 43% continued to receive regular imaging by 30-month and 60-month of follow-up, respectively. Survivors were less likely to receive imaging if they were older, black, unmarried, received no adjuvant therapy, had stage I disease (vs. stage II) or were diagnosed before 2006. In adjusted analysis, survivors who received recommended imaging up to 18 months from surgery experienced better survival compared to survivors who did not (HR 0.92; 95% CI 0.85-0.99). Survival benefit was also observed in survivors who underwent regular imaging up to 5 years from surgery (HR 0.68; 95% CI 0.60-0.78).

CONCLUSIONS

More than half the lung cancer survivors received less than the recommended long-term surveillance imaging. Long-term adherence to surveillance is associated with improved survival. Our study provides evidence to support the current clinical guidelines for surveillance for lung cancer survivors that are primarily consensus-based at present.

Controversies in lung cancer screening

There remains an extensive debate over lung cancer screening, with lobbying for and against screening for very compelling reasons. The National Lung Screening Trial, International Early Lung Cancer Program, and other major screening studies favor screening with low-dose CT scans and have shown a reduction in lung cancer--specific mortality. The increasing incidence of lung cancer and the dismal survival rate for advanced disease despite improved multimodality therapy have sparked an interest in the implementation of national lung cancer screening. Concerns over imaging workflow, radiation dose, management of small nodules, overdiagnosis bias, lead-time and length-time bias, emerging new technologies, and cost-effectiveness continue to be debated. The authors address each of these issues as they relate to radiologic practice.

Cost-effectiveness of baseline low-dose computed tomography screening for lung cancer: the Israeli experience

OBJECTIVE

Reduced mortality with low-dose computed tomography (LDCT) lung cancer screening was demonstrated in a large randomized controlled study of high-risk individuals. Cost-effectiveness must be assessed before routine LDCT screening is considered. We aimed to evaluate the cost-effectiveness of LDCT lung cancer screening in Israel.

METHODS

A decision analytic framework was used to evaluate the decision to screen or not screen from the health system perspective. The screening arm included 842 moderate-to-heavy smokers aged 45 years or older, screened at Hadassah-Hebrew University Medical Center from 1998 to 2004. In the usual-care arm, stage distribution and stage-specific life expectancy were obtained from the Israel National Cancer Registry data for 1994 to 2006. Lifetime stage-specific costs were estimated from medical records of patients diagnosed and treated at Hadassah Medical Center in the period 2003 to 2004. The analysis considered possible biases-lead time, overdiagnosis, and self-selection. Cost per quality-adjusted-life-year (QALY) gained by screening was estimated.

RESULTS

Base-case incremental cost per QALY gained was $1464 (2011 prices). Extensive sensitivity analysis affirmed the low cost per QALY gained. The cost per QALY gained is lower than $10,000 with probability 0.937 and is lower than $20,000 with probability 0.978.

CONCLUSIONS

Our analysis suggests that baseline LDCT lung cancer screening in Israel presents a good value for the money and should be considered for inclusion in the National List of Health Services financed publicly.

Overwhelming support among urban Irish COPD patients for lung cancer screening by low-dose CT scan

PURPOSE

The National Lung Screening Trial (NLST) has renewed interest in low-dose computed tomography (LDCT) screening for lung cancer. Smokers may be less receptive toward LDCT screening, however, compared with never smokers. The views of patients with COPD, a particularly high-risk group, toward LDCT screening for lung cancer are currently unknown. We therefore evaluated attitudes of patients with COPD toward LDCT screening for lung cancer.

METHODS

Interviews with Irish patients with COPD who satisfied NLST eligibility criteria were conducted in clinical settings using a questionnaire based on that of a comparable study of U.S. current/former smokers of unspecified disease status.

RESULTS

A total of 142 subjects had a mean age of 65.09 ± 6.07 years (46.4 % were male, mean pack years 54.5 ± 33.3, mean FEV1 59.16 ± 23 %); 97.8 % had an identifiable usual source of healthcare. Compared with data from a U.S. cohort of current/former smokers, a higher proportion of Irish COPD smokers: believed that they were at risk for lung cancer (63.6 vs. 15.7 %); believed that early detection improved chances of survival (90 vs. 51.2 ); were willing to consider LDCT screening (97.9 vs. 78.6 %); were willing to pay for a LDCT scan (68.6 vs. 36.2 %); and were willing to accept treatment recommendations arising (95.7 vs. 56.2 %; p < 0.0001 for all comparisons).

CONCLUSIONS

Urban Irish smokers with COPD who would be eligible for LDCT screening are almost universally in favor of being screened and treated for screening-detected lung cancers. This readily accessible high-risk population should be actively targeted in future screening programs.

Benefits and harms of CT screening for lung cancer: a systematic review

CONTEXT

Lung cancer is the leading cause of cancer death. Most patients are diagnosed with advanced disease, resulting in a very low 5-year survival. Screening may reduce the risk of death from lung cancer.

OBJECTIVE

To conduct a systematic review of the evidence regarding the benefits and harms of lung cancer screening using low-dose computed tomography (LDCT). A multisociety collaborative initiative (involving the American Cancer Society, American College of Chest Physicians, American Society of Clinical Oncology, and National Comprehensive Cancer Network) was undertaken to create the foundation for development of an evidence-based clinical guideline.

DATA SOURCES

MEDLINE (Ovid: January 1996 to April 2012), EMBASE (Ovid: January 1996 to April 2012), and the Cochrane Library (April 2012).

STUDY SELECTION

Of 591 citations identified and reviewed, 8 randomized trials and 13 cohort studies of LDCT screening met criteria for inclusion. Primary outcomes were lung cancer mortality and all-cause mortality, and secondary outcomes included nodule detection, invasive procedures, follow-up tests, and smoking cessation.

DATA EXTRACTION

Critical appraisal using predefined criteria was conducted on individual studies and the overall body of evidence. Differences in data extracted by reviewers were adjudicated by consensus.

RESULTS

Three randomized studies provided evidence on the effect of LDCT screening on lung cancer mortality, of which the National Lung Screening Trial was the most informative, demonstrating that among 53,454 participants enrolled, screening resulted in significantly fewer lung cancer deaths (356 vs 443 deaths; lung cancer−specific mortality, 274 vs 309 events per 100,000 person-years for LDCT and control groups, respectively; relative risk, 0.80; 95% CI, 0.73-0.93; absolute risk reduction, 0.33%; P = .004). The other 2 smaller studies showed no such benefit. In terms of potential harms of LDCT screening, across all trials and cohorts, approximately 20% of individuals in each round of screening had positive results requiring some degree of follow-up, while approximately 1% had lung cancer. There was marked heterogeneity in this finding and in the frequency of follow-up investigations, biopsies, and percentage of surgical procedures performed in patients with benign lesions. Major complications in those with benign conditions were rare.

CONCLUSION

Low-dose computed tomography screening may benefit individuals at an increased risk for lung cancer, but uncertainty exists about the potential harms of screening and the generalizability of results.

Healthcare use after screening for lung cancer

BACKGROUND

To evaluate the benefits of lung cancer screening, all effects of screening need to be considered. The aim of this study was to determine whether screening had an effect on healthcare use, specifically whether use increased for those with a false-positive or indeterminate screening result.

METHODS

Recruited were 400 individuals participating in a lung cancer screening study at the University of Pittsburgh. Self-reported outpatient healthcare use information was collected for the 6 months before, 0 to 6 months after, and 6 to 12 months after screening. The screening outcomes were negative, indeterminate, and suspicious. Repeated-measures Poisson regression models were used to examine changes in use over time and how changes over time varied among the screening outcome groups.

RESULTS

Approximately 58% of participants had a negative screening result, 36% had an indeterminate result, and approximately 6% had a suspicious result. The percentage of individuals who had any incidence of each type of outpatient use increased after screening, with the greatest increase noted for those with a suspicious screening result. Adjusted mean use significantly increased for nearly all types of use and for all 3 screening results categories in the 6 months after screening, but mostly declined to prescreening levels in the next 6 months.

CONCLUSIONS

Outpatient healthcare use was found to increase after screening for all individuals who were screened for lung cancer, regardless of the screening finding. The cost of the lung-related visits alone was substantial. Therefore, if lung cancer screening prevalence is increased, attendant follow-up healthcare costs are also likely to increase.