Cost-Effectiveness Analysis of Risk Factor-Based Lung Cancer Screening Program by Low-Dose Computer Tomography in Current Smokers in China

Abstract

Although the effectiveness of lung cancer screening by low-dose computed tomography (LDCT) could be shown in China, there could be variation in the evidence concerning the economic impact. Our study explores the cost-effectiveness of lung cancer screening and optimizes the best definition of a high-risk population. A Markov model consisting of the natural history and post-diagnosis states was constructed to estimate the costs and quality-adjusted life years (QALYs) of LDCT screening compared with no screening. A total of 36 distinct risk factor-based screening strategies were assessed by incorporating starting ages of 40, 45, 50, 55, 60 and 65 years, stopping ages of 69, 74 and 79 years as well as smoking eligibility criteria. Screening data came from community-based mass screening with LDCT for lung cancer in Guangzhou. Compared with no screening, all screening scenarios led to incremental costs and QALYs. When the willingness-to-pay (WTP) threshold was USD37,653, three times the gross domestic product (GDP) per capita in China, six of nine strategies on the efficiency frontier may be cost-effective. Annual screening between 55 and 79 years of age for those who smoked more than 20 pack-years, which yielded an incremental cost-effectiveness ratio (ICER) of USD35,000.00 per QALY gained, was considered optimal. In sensitivity analyses, the result was stable in most cases. The trends of the results are roughly the same in scenario analyses. According to the WTP threshold of different regions, the optimal screening strategies were annual screening for those who smoked more than 20 pack-years, between 50 and 79 years of age in Zhejiang province, 55-79 years in Guangdong province and 65-74 years in Yunnan province. However, annual screening was unlikely to be cost-effective in Heilongjiang province under our modelling assumptions, indicating that tailored screening policies should be made regionally according to the local epidemiological and economic situation.

Keywords: China; LDCT screening; cost-effectiveness analysis; current smokers; lung cancer.

Figure 1

Markov model for natural history and post-diagnosis. LC, lung cancer.

Figure 2

Cost-effectiveness plane of all 36 screening strategies versus no screening in the base-case analysis. QALYs, quality-adjusted life years; GDP, gross domestic product.

Figure 3

Tornado diagrams of the one-way sensitivity analysis. (a) Strategy 6 (55–79-year-olds with a smoking history of ≥20 pack-years) versus strategy 5 (60–79-year-olds with a smoking history of ≥20 pack-years). (b) Strategy 7 (50–79-year-olds with a smoking history of ≥20 pack-years) versus strategy 6 (55–79-year-olds with a smoking history of ≥20 pack-years).LDCT, low-dose computed tomography; RR, relative risk; QALY, quality-adjusted life year; GDP, gross domestic product.

Figure 4

Scatter plots and cost-effectiveness acceptability curves of probability sensitivity analysis. (a) Strategy 6 (55–79-year-olds with a smoking history of ≥20 pack-years) versus strategy 5 (60–79-year-olds with a smoking history of ≥20 pack-years). (b) Strategy 7 (50–79-year-olds with a smoking history of ≥20 pack-years) versus strategy 6 (55–79-year-olds with a smoking history of ≥20 pack-years). GDP, gross domestic product; QALY, quality-adjusted life year; y, year-old; py, pack-years.