Risk-based lung cancer screening more cost-effective than USPSTF strategy, study finds
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Risk-based strategies for lung cancer screening were more cost-effective than screening based on age and smoking history as recommended by the U.S. Preventive Services Task Force, a recent study found.
The USPSTF updated its recommendations for lung cancer screening (LCS) in 2021, lowering the starting age from 55 to 50 years and the minimum smoking history from 30 to 20 pack-years.
Iakovos Toumazis, PhD, an assistant professor in the department of health services research at the University of Texas MD Anderson Cancer Center, and colleagues wrote that the USPSTF reviewed the performance of two strategies when developing their guidance:
- risk model-based strategies that select people based on their personal lung cancer risk; and
- categorical age-smoking strategies that select people based on their categorical age and smoking history.
Previous research has suggested that risk model-based strategies could improve sensitivity while avoiding greater mortality compared with categorical age-smoking strategies, Toumazis and colleagues wrote in Annals of Internal Medicine. However, data on the cost-effectiveness of risk model-based strategies “have been largely lacking,” they added.
“The cost-effectiveness of risk model-based screening could depend on the risk threshold used to select people for screening given the differences in health outcomes associated with screening persons from different risk strata,” they wrote.
The researchers conducted a modeling analysis to compare the cost-effectiveness of risk model-based strategies vs. the USPSTF guidance. The analysis involved four microsimulation models of the Cancer Intervention and Surveillance Modeling Network Lung Working Group, which informed the USPSTF’s guidance on LCS.
Toumazis and colleagues simulated lung cancer-related events for 1 million men and women. They used smoking patterns of the 1960 U.S. birth cohort, which is “representative of the U.S. population targeted by screening,” the researchers wrote. Simulated participants were aged 45 years at the start of the study and were followed until 90 years or death.
The researchers used the Prostate, Lung, Colorectal and Ovarian modified 2012 risk prediction model (PLCOm2012) and the Lung Cancer Death Risk Assessment Tool (LCDRAT) to assess individuals’ lung cancer risks. They used 6-year risk thresholds ranging from 0.5% to 2.25%. Screenings were only considered cost-effective if they were:
- on the cost-effectiveness efficiency frontier, “that is, the line segments connecting strategies that yield the highest health benefit at a given level of cost”; and
- had an incremental cost-effectiveness ratio (ICER) of less than $100,000 per quality-adjusted life-year (QALY).
Categorical age-smoking strategies ‘strongly dominated’
Overall, when using the PLCOm2012 model, the categorical age-smoking strategies “were strongly dominated by risk model-based strategies,” meaning they were “more costly yet yielded fewer QALYs,” the researchers wrote.
Of the risk model-based strategies on the cost-effectiveness frontier that started screening at age 50 years, six strategies with a 6-year risk threshold of 1.2% or greater were cost effective.
Specifically, the researchers reported that the strategy with a threshold of 1.2% had an ICER of $94,659. This strategy also produced the greatest health benefit among cost-effective strategies and yielded a higher reduction in lung cancer mortality (12.4%) compared with the 2021 USPSTF recommendation (11.8%). Both maintained a similar level of screening coverage.
The LCDRAT model produced similar 6-year lung cancer incidence rates compared with the PLCOm2012 model, though the strategy that produced the highest QALYs had a 6-year risk threshold of 1.1%.
The researchers explained that discrepancies in the optimal risk thresholds between the LCDRAT and PLCOm2012 models “highlight the importance for lung cancer screening programs to use model-specific risk thresholds.”
“Ultimately, optimal risk thresholds must be tailored to specific settings based on practical considerations, benefits and harms tradeoffs, and resource constraints,” they wrote.
Despite potential cost-effectiveness, LCS barriers remain
Before embracing risk model-based strategies, Renda S. Wiener, MD, MPH, a professor of medicine at the Boston University Chobanian and Avedisian School of Medicine, and Michael K. Gould, MD, MS, a professor at the Kaiser Permanente Bernard J. Tyson School of Medicine, wrote in a related editorial that “it is crucial to consider implications for safety, patient-centeredness, timeliness, and equity.”
“For example, lowering the lung cancer risk threshold expands the LCS-eligible population, thereby preventing more lung cancer deaths but would also expose more people to iatrogenic harms, including serious events such as unnecessary invasive procedures and treatment of over-diagnosed cancers,” they wrote.
Wiener and Gould also noted that it is ultimately on clinicians to assist patients in weighing the benefits and harms of lung cancer screening through shared decision-making, regardless of screening criteria.
“Some believe risk model-based approaches are inherently more person-centered because they supply people with personalized data to inform decision making,” they wrote. “Yet, shared decision-making involves more than information provision; it entails helping patients understand the information and weigh the tradeoffs of LCS in the context of their own values, preferences and goals. It is not yet clear how to make risk model output comprehensible to patients, particularly those with low health literacy.”
References:
- Toumazis I, et al. Ann Intern Med. 2023;doi:10.7326/M22-2216.
- Weiner R, Gould M. Ann Intern Med. 2023;doi:10.7326/M23-0230.
Perspective
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This study is another attempt at trying to prove that risk model-based screening may be better than using categorical age-smoking criteria from USPSTF. It shows that using a 1.2% PLCO risk threshold to identify a screening population is more cost effective while screening the same amount of individuals. In addition, it also leads to a greater lung cancer mortality reduction (12.4% vs. 11.8%).
Interestingly, using an even higher risk population (like > 2% risk) becomes more cost effective but leads to screening fewer individuals and drops the mortality reduction. Hence, picking the correct threshold may be very important if risk-based criteria become the standard clinical practice.
Clinically, while the USPSTF criteria are most likely to be widely used, this study helps support screening for individuals who may not exactly meet the USPSTF criteria but are above the PLCO risk threshold of 1.2%.
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