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. 2014 May 20;160(10):672-83.
doi: 10.7326/M13-2498.

Cost-effectiveness of the children's oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure

F Lennie Wong, Smita Bhatia, Wendy Landier, Liton Francisco, Wendy Leisenring, Melissa M Hudson, Gregory T Armstrong, Ann Mertens, Marilyn Stovall, Leslie L Robison, Gary H Lyman, Steven E Lipshultz, Saro H Armenian

Cost-effectiveness of the children's oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure

F Lennie Wong et al. Ann Intern Med. .

Abstract

Background: Childhood cancer survivors treated with anthracyclines are at high risk for asymptomatic left ventricular dysfunction (ALVD), subsequent heart failure, and death. The consensus-based Children's Oncology Group (COG) Long-Term Follow-up Guidelines recommend lifetime echocardiographic screening for ALVD.

Objective: To evaluate the efficacy and cost-effectiveness of the COG guidelines and to identify more cost-effective screening strategies.

Design: Simulation of life histories using Markov health states.

Data sources: Childhood Cancer Survivor Study; published literature.

Target population: Childhood cancer survivors.

Time horizon: Lifetime.

Perspective: Societal.

Intervention: Echocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and β-blocker therapies after ALVD diagnosis.

Outcome measures: Quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure.

Results of base-case analysis: The COG guidelines versus no screening have an ICER of $61 500, extend life expectancy by 6 months and QALYs by 1.6 months, and reduce the cumulative incidence of heart failure by 18% at 30 years after cancer diagnosis. However, less frequent screenings are more cost-effective than the guidelines and maintain 80% of the health benefits.

Results of sensitivity analysis: The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER.

Limitation: Lifetime non-heart failure mortality and the cumulative incidence of heart failure more than 20 years after diagnosis were extrapolated; the efficacy of ACE inhibitor and β-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown).

Conclusion: The COG guidelines could reduce the risk for heart failure in survivors at less than $100 000/QALY. Less frequent screening achieves most of the benefits and would be more cost-effective than the COG guidelines.

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Conflict of interest statement

Conflicts of interest

We declare that we have no conflict of interest.

Figures

Appendix Figure 1
Appendix Figure 1
Four-health state transition diagram. ALVD = asymptomatic left ventricular dysfunction HF = heart failure
Appendix Figure 2
Appendix Figure 2
Annual incidence of HF by years since cancer diagnosis, for A) age at cancer diagnosis < 5 years; B) age at cancer diagnosis ≥ 5 years HF = heart failure
Appendix Figure 2
Appendix Figure 2
Annual incidence of HF by years since cancer diagnosis, for A) age at cancer diagnosis < 5 years; B) age at cancer diagnosis ≥ 5 years HF = heart failure
Appendix Figure 3
Appendix Figure 3
Annual non-HF mortality by attained age HF = heart failure RR = relative risk (compared to the U.S. population)
Appendix Figure 4
Appendix Figure 4
Two-way sensitivity analyses for ICER, by varying the efficacy of ALVD treatment and the sensitivity and specificity of echocardiography for detecting ALVD ALVD = asymptomatic left ventricular dysfunction ICER = incremental cost-effectiveness ratio QALY = quality-adjusted life-year
Figure 1
Figure 1
Tornado diagrams of the one-way sensitivity analyses for ICER and the percent reduction in the cumulative incidence of HF at 30 years after cancer diagnosis, by varying key variables. ACE = angiotensin-converting enzyme HF = heart failure ICER = incremental cost-effectiveness ratio QALY = quality-adjusted life-year
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References

    1. Lipshultz SE, Alvarez JA, Scully RE. Anthracycline associated cardiotoxicity in survivors of childhood cancer. Heart. 2008;94(4):525–33. - PubMed
    1. Lipshultz SE, Adams MJ, Colan SD, Constine LS, Herman EH, Hsu DT, et al. Long-term Cardiovascular Toxicity in Children, Adolescents, and Young Adults Who Receive Cancer Therapy: Pathophysiology, Course, Monitoring, Management, Prevention, and Research Directions: A Scientific Statement From the American Heart Association. Circulation. 2013 - PubMed
    1. Lipshultz SE, Colan SD, Gelber RD, Perez-Atayde AR, Sallan SE, Sanders SP. Late cardiac effects of doxorubicin therapy for acute lymphoblastic leukemia in childhood. N Engl J Med. 1991;324(12):808–15. - PubMed
    1. Lipshultz SE, Lipsitz SR, Sallan SE, Simbre VCn, Shaikh SL, Mone SM, et al. Long-term enalapril therapy for left ventricular dysfunction in doxorubicin-treated survivors of childhood cancer. J Clin Oncol. 2002;20(23):4517–22. - PubMed
    1. Lipshultz SE, Lipsitz SR, Sallan SE, Dalton VM, Mone SM, Gelber RD, et al. Chronic progressive cardiac dysfunction years after doxorubicin therapy for childhood acute lymphoblastic leukemia. J Clin Oncol. 2005;23(12):2629–36. - PubMed

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