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. 2024 Feb;20(2):278-290.
doi: 10.1200/OP.23.00495. Epub 2023 Dec 12.

Cost-Effectiveness Analysis of Screening for Pancreatic Cancer Among High-Risk Populations

Mary Linton B Peters  1   2 , Andrew Eckel  2 , Claudia L Seguin  3 , Barak Davidi  2 , David H Howard  4 , Amy B Knudsen  2   5 , Pari V Pandharipande  3
Affiliations

Cost-Effectiveness Analysis of Screening for Pancreatic Cancer Among High-Risk Populations

Mary Linton B Peters et al. JCO Oncol Pract. 2024 Feb.

Abstract

Purpose: We evaluated the potential cost-effectiveness of combined magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) screening for pancreatic ductal adenocarcinoma (PDAC) among populations at high risk for the disease.

Methods: We used a microsimulation model of the natural history of PDAC to estimate the lifetime health benefits, costs, and cost-effectiveness of PDAC screening among populations with specific genetic risk factors for PDAC, including BRCA1 and BRCA2, PALB2, ATM, Lynch syndrome, TP53, CDKN2A, and STK11. For each high-risk population, we simulated 29 screening strategies, defined by starting age and frequency. Screening included MRI with follow-up EUS in a subset of patients. Costs of tests were based on Medicare reimbursement for MRI, EUS, fine-needle aspiration biopsy, and pancreatectomy. Cancer-related cost by stage of disease and phase of treatment was based on the literature. For each high-risk population, we performed an incremental cost-effectiveness analysis, assuming a willingness-to-pay (WTP) threshold of $100,000 US dollars (USD) per quality-adjusted life year (QALY) gained.

Results: For men with relative risk (RR) 12.33 (CDKN2A) and RR 28 (STK11), annual screening was cost-effective, starting at age 55 and 40 years, respectively. For women, screening was only cost-effective for those with RR 28 (STK11), with annual screening starting at age 45 years.

Conclusion: Combined MRI/EUS screening may be a cost-effective approach for the highest-risk populations (among mutations considered, those with RR >12). However, for those with moderate risk (RR, 5-12), screening would only be cost-effective at higher WTP thresholds (eg, $200K USD/QALY) or with once-only screening.

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Conflict of interest statement

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Mary Linton B. Peters

Stock and Other Ownership Interests: Lilly, Medtronic, Procter & Gamble, Merck, Abbott Laboratories, Amgen, Lilly, Johnson & Johnson, Medtronic, Pfizer, Abbott Laboratories, Agios, Merck

Research Funding: Taiho Pharmaceutical (Inst), AstraZeneca (Inst), Exelixis (Inst), BeiGene (Inst), Berg Pharma (Inst), Merck (Inst), Bayer (Inst), Nucana (Inst), Lilly (Inst), Helsinn Therapeutics (Inst)

Open Payments Link: https://openpaymentsdata.cms.gov/physician/1369301

David H. Howard

Honoraria: WebMD

Consulting or Advisory Role: The Center for Discovery, Association for Frontotemporal Degeneration

Research Funding: Pfizer

Amy B. Knudsen

Employment: ZOLL Medical Corporation

Leadership: ZOLL Medical Corporation

Pari V. Pandharipande

Leadership: RSNA, Association for University Radiologists (AUR) + General Electric (GE)

Honoraria: Academic Institutions

Research Funding: NIH (Inst)

Patents, Royalties, Other Intellectual Property: Royalties for patent for genetics-related innovation, paid through Brigham and Women's Hospital to my husband. Not related to my current research, to my knowledge

Travel, Accommodations, Expenses: Association for University Radiologists (AUR) + General Electric (GE), RSNA

No other potential conflicts of interest were reported.

Figures

FIG 1.
FIG 1.
Model schema. The health states emphasized in a bold outline (high-risk cyst and undetected stage I) are the targets of screening. The dashed arrows represent risk-reducing surgery and early cancer detection. PDAC, Pancreatic Ductal Adenocarcinoma; PanIN, Pancreatic Intraepithelial Neoplasia.
FIG 2.
FIG 2.
Quality-adjusted life-years gained and lifetime PDAC-related costs compared with no screening for 29 PDAC screening strategies among men with a STK11 mutation (RR, 28). Each datapoint represents a screening strategy. Strategies that make up the outer envelope are efficient, and the line that connects them is the efficient frontier. The incremental cost-effectiveness ratios for the efficient strategies are noted. For this population, three efficient strategies were identified: no screening, annual screening starting at age 45 years, and annual screening starting at age 40 years. Annual screening starting at age 50 years is close to but just below this frontier. PDAC, pancreatic ductal adenocarcinoma; QALY, quality-adjusted life year; RR, relative risk; USD, US dollars.
FIG 3.
FIG 3.
Deterministic sensitivity analyses on the cost-effective strategy at a WTP threshold of $100K USD and $200K USD (men). This figure shows the cost-effective screening strategy for each cohort defined by the RR of PDAC (along the top), each uncertainty scenario (along the left), and each assumption about the WTP for a quality-adjusted year of life gained (along the bottom). Within each box, the symbols represent the cost-effective strategy (no screening, screening once, screening every 1, 2, or 5 years, with starting at age ranging from 40 to 75 years, in 5-year increments) for each of the nine cohorts. For example, with the low discount rate assumption, for RRs of 1-3.55, no screening is the cost-effective strategy. For RRs of 5.71-6.7, screening once at age 60 years is cost-effective. At RR 12.33, annual screening starting at age 50 years is cost-effective, and at RR 28, annual screening starting at age 40 years is cost-effective. The right-hand column shows the same analysis using a WTP threshold of $200K USD/QALY gained. PDAC, pancreatic ductal adenocarcinoma; QALY, quality-adjusted life year; RR, relative risk; USD, US dollars; WTP, willingness-to-pay.
FIG 4.
FIG 4.
Deterministic sensitivity analyses on the cost-effective strategy at a WTP threshold of $100K USD and $200K USD (women). This figure shows the cost-effective screening strategy for each cohort defined by the RR of PDAC (along the top), each uncertainty scenario (along the left), and each assumption about the WTP for a quality-adjusted year of life gained (along the bottom). Within each box, the symbols represent the cost-effective strategy (no screening, screening once, screening every 1, 2, or 5 years, starting at age ranging from 40 to 75 years, in 5-year increments) for each of the nine cohorts. The right-hand column shows the same analysis using a WTP threshold of $200K USD/QALY gained. PDAC, pancreatic ductal adenocarcinoma; QALY, quality-adjusted life year; RR, relative risk; USD, US dollars; WTP, willingness-to-pay.
FIG A1.
FIG A1.
Efficient frontiers for all cohorts. QALY, quality-adjusted life year, US dollars.
FIG A2.
FIG A2.
Deterministic sensitivity analysis. ICER, incremental cost-effectiveness ratio; RR, relative risk; USD, US dollars.
FIG A3.
FIG A3.
Sensitivity analysis on surgical mortality. USD, US dollars; WTP, willingness-to-pay.
See this image and copyright information in PMC

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