Population-Based Screening Using Low-Dose Chest Computed Tomography: A Systematic Review of Health Economic Evaluations

Abstract

Background: Chest low-dose computed tomography (LDCT) is a promising technology for population-based screening because it is non-invasive, relatively inexpensive, associated with low radiation and highly sensitive to lung cancer. To improve the cost-effectiveness of lung cancer screening, simultaneous screening for other diseases could be considered. This systematic review was conducted to analyse studies that published evidence on the cost-effectiveness of chest LDCT screening programs for different diseases.

Methods: Scopus and PubMed were searched for English publications (1 January 2011-22 July 2022) using search terms related to screening, computed tomography and cost-effectiveness. An additional search specifically searched for the cost-effectiveness of screening for lung cancer, chronic obstructive pulmonary disease or cardiovascular disease. Included publications should present a full health economic evaluation of population screening with chest LDCT. The extracted data included the disease screened for, model type, country context of screening, inclusion of comorbidities or incidental findings, incremental costs, incremental effects and the resulting cost-effectiveness ratio amongst others. Reporting quality was assessed using the 2022 Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

Results: The search yielded 1799 unique papers, of which 43 were included. Most papers focused on lung cancer screening (n = 40), and three were on coronary calcium scoring. Microsimulation was the most commonly applied modelling type (n = 16), followed by life table analysis (n = 10) and Markov cohort models (n = 10). Studies reflected the healthcare context of the US (n = 15), Canada (n = 4), the UK (n = 3) and 13 other countries. The reported incremental cost-effectiveness ratio ranged from US$10,000 to US$90,000/quality-adjusted life year (QALY) for lung cancer screening compared to no screening and was US$15,900/QALY-US$45,300/QALY for coronary calcium scoring compared to no screening.

Discussion: Almost all health economic evaluations of LDCT screening focused on lung cancer. Literature regarding the health economic benefits of simultaneous LDCT screening for multiple diseases is absent. Most studies suggest LDCT screening is cost-effective for current and former smokers aged 55-74 with a minimum of 30 pack-years of smoking history. Consequently, more evidence on LDCT is needed to support further cost-effectiveness analyses. Preferably evidence on simultaneous screening for multiple diseases is needed, but alternatively, on single-disease screening.

Registration of systematic review: Prospective Register of Ongoing Systematic Reviews registration CRD42021290228 can be accessed https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=290228 .

Fig. 1

Visual representation of the age of the target screening population for lung cancer screening. A continuous line represents once-off screening as each black vertical line indicates a screening round. At the end of each study, the smoking requirements are shown. “30;10” indicates > 30 pack-years smoked and < 10 years since cessation. “0;0” indicates that there were no minimum number of pack-years and 0 years since smoking cessation (only current smokers). “NA;NA” indicates that minimum pack-years is not applicable because smoking was not a requirement (in studies that use a risk calculator to identify eligible individuals) and no maximum years since smoking cessation in the eligible population. Whether a screening strategy is classified as cost-effective or not was firstly based on the reported study conclusion or, if no conclusion was presented, by comparing the base-case results in the paper with the provided willingness-to-pay threshold. NLST National Lung Screening Trial. NA not applicable. *Study based (partially) on NLST data

Fig. 2

Lung cancer screening incremental cost-effectiveness plane with LYG per person plotting each study, indicating the context country. Whether a screening strategy is classified as cost-effective or not was firstly based on the reported study conclusion or, if no conclusion was presented, by comparing the base-case results in the paper with the provided willingness-to-pay threshold. LYG life years gained

Fig. 3

Lung cancer screening incremental cost-effectiveness plane with incremental QALYs per person plotting each study, indicating the context country. Whether a study is classified as cost-effective or not was firstly based on the reported study conclusion or, if no conclusion was presented, the base-case results were compared to the provided willingness-to-pay threshold. QALY quality-adjusted life year