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.
Siegel R, Ward E, Brawley O. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin 2011;61:212–236.
Aberle DR, Adams AM, Berg CD. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395–409.
National Institute for Occupational Safety and Health. Helical CT scans and lung cancer screening. Available at: http://www.cdc.gov/niosh/blog/nsb011011_ct.html. Accessed October 20, 2011.
Fiore K. Mortality benefit seen with CT halts lung cancer screening trial. MedPage Today. Available at: http://www.medpagetoday.com/HematologyOncology/LungCancer/23158. Accessed October 20, 2011.
U.S. Census Bureau. Population Estimates. U.S. Census Bureau, 2010. Available at: http://www.census.gov/popest/estimates.php. Accessed October 20, 2011.
Pleis JR, Ward BW, Lucas JW. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009. Vital Health Stat 2010;10:1–217.
Centers for Disease Control and Prevention. Decrease in smoking prevalence—Minnesota, 1999–2010. MMWR Morb Mortal Wkly Rep 2011;60:138–141.
Breen N, Gentleman JF, Schiller JS. Update on mammography trends: comparisons of rates in 2000, 2005, and 2008. Cancer 2011;117:2209–2218.
Centers for Disease Control and Prevention. Vital signs: colorectal cancer screening, incidence, and mortality—United States, 2002–2010. MMWR Morb Mortal Wkly Rep 2011;60:884–889.
National Cancer Institute. Surveillance Epidemiology and End Results. National Institutes of Health, 2011. Available at: http://seer.cancer.gov/. Accessed October 24, 2011.
Centers for Medicare & Medicaid Services. U.S. Department of Health & Human Services, 2011. Available at: http://www.cms.gov/. Accessed October 24, 2011.
Mariotto AB, Yabroff KR, Shao Y. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst 2011;103:117–128.
Ou SH, Zell JA. Validation study of the proposed IASLC staging revisions of the T4 and M non-small cell lung cancer descriptors using data from 23,583 patients in the California Cancer Registry. J Thorac Oncol 2008;3:216–227.
Sandler A, Gray R, Perry MC. Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer. N Engl J Med 2006;355:2542–2550.
Blue Cross of Idaho. MP 6.01.30: Screening for lung cancer using CT scanning or chest radiographs. Available at: https://www.bcidaho.com/providers/medical_policies/rad/mp_60130.asp. Accessed November 1, 2011.
Centers for Medicare and Medicaid Services. Medicare National Coverage Determinations Manual. Baltimore, MD: U.S. Department of Health & Human Services; 2011:1–143.
Black C, Bagust A, Boland A. The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: systematic reviews. Health Technol Assess 2006;10:8.
Chirikos TN, Hazelton T, Tockman M. Screening for lung cancer with CT: a preliminary cost-effectiveness analysis. Chest 2002;121:1507–1514.
Mahadevia PJ, Fleisher LA, Fric KD. Lung, cancer screening with helical computed tomography in older adult smokers: a decision and cost-effectiveness analysis. JAMA 2003;289:313–322.
Marshall D, Simpson KN, Earle CC. Potential cost-effectiveness of one-time screening for lung cancer (LC) in a high risk cohort. Lung Cancer 2001;32:227–236.
Wisnivesky JP, Mushlin AI, Sicherman N. The cost-effectiveness of low-dose CT screening for lung cancer: preliminary results of baseline screening. Chest 2003;124:614–621.
Manser R, Dalton A, Carter R. Cost-effectiveness analysis of screening for lung cancer with low dose spiral CT (computed tomography) in the Australian setting. Lung Cancer 2005;48:171–185.
Castleberry AW, Smith D, Anderson C. Cost of a 5-year lung cancer survivor: symptomatic tumour identification vs proactive computed tomography screening. Br J Cancer 2009;101:882–896.
McMahon PM, Kong CY, Bouzan C. Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol 2011;6:1841–1848.
Weinstein MC, Siegel JE, Gold MR. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 1996;276:1253–1258.