Lung cancer is the leading cause of cancer deaths in the United States, accounting for 221,000 new cancer cases and 157,000 deaths in 2011.1 This high mortality rate occurs partly because most patients present with advanced stages, when the disease is rarely curable. Lung cancer screening tests can potentially reduce cancer mortality through detecting tumors at earlier stages, when treatments have higher chances of cure.2,3
The NCI-sponsored National Lung Screening Trial (NLST) is the first randomized trial to show a reduction in lung cancer mortality from any screening modality; in this case, low-dose chest CT (LDCT) screening.4 From August 2002 to April 2004, the study enrolled 53,454 high-risk individuals aged 55 to 74 years, defined as current smokers of 30 packs-per-year (ppy) or more, or former smokers with the same smoking history who quit no longer than 15 years before enrollment, and randomly assigned them to receive screening with LDCT versus chest radiograph. Persons assigned to the intervention arm received annual LDCT scans for 3 consecutive years and underwent follow-up thereafter, and persons assigned to the control arm received annual chest radiographs for the same period. With a median follow-up of 6.5 years, the study showed a 20% relative reduction in lung cancer mortality favoring the LDCT screening arm.4
The NLST results have sparked intense debate among health care providers and policy-makers about the logistics and economic implications of implementing LDCT screening nationwide.5,6 The main concerns include the financial burden that a national LDCT screening program would impose on the U.S. health care system, which currently struggles to contain escalating expenditures, and the patient burden that results from a high false-positive screening rate (estimated as 96.4% in the NLST), including unnecessary costs and harms caused by additional imaging tests and surgical procedures.
In response to these concerns, the authors developed a budget impact model to estimate the additional national expenditures expected if LDCT is widely adopted in the United States. Because part of the national burden of screening will be paid directly by patients in the form of copays, the authors also estimated the out-of-pocket patient costs for the population that would be eligible for LDCT screening. Finally, they reviewed the pertinent literature to identify factors that will most influence the cost-effectiveness of this test.
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