Department of Cancer Epidemiology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China.
Center for Global Health, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100005, China.
BMC Med. 2024 Feb 19;22(1):73. doi: 10.1186/s12916-024-03292-4.
Annual screening through low-dose computed tomography (LDCT) is recommended for heavy smokers. However, it is questionable whether all individuals require annual screening given the potential harms of LDCT screening. This study examines the benefit-harm and cost-effectiveness of risk-based screening in heavy smokers and determines the optimal risk threshold for screening and risk-stratified screening intervals.
We conducted a comparative cost-effectiveness analysis in China, using a cohort-based Markov model which simulated a lung cancer screening cohort of 19,146 heavy smokers aged 50 ~ 74 years old, who had a smoking history of at least 30 pack-years and were either current smokers or had quit for < 15 years. A total of 34 risk-based screening strategies, varying by different risk groups for screening eligibility and screening intervals (1-year, 2-year, 3-year, one-off, non-screening), were evaluated and were compared with annual screening for all heavy smokers (the status quo strategy). The analysis was undertaken from the health service perspective with a 30-year time horizon. The willingness-to-pay (WTP) threshold was adopted as three times the gross domestic product (GDP) of China in 2021 (CNY 242,928) per quality-adjusted life year (QALY) gained.
Compared with the status quo strategy, nine risk-based screening strategies were found to be cost-effective, with two of them even resulting in cost-saving. The most cost-effective strategy was the risk-based approach of annual screening for individuals with a 5-year risk threshold of ≥ 1.70%, biennial screening for individuals with a 5-year risk threshold of 1.03 ~ 1.69%, and triennial screening for individuals with a 5-year risk threshold of < 1.03%. This strategy had the highest incremental net monetary benefit (iNMB) of CNY 1032. All risk-based screening strategies were more efficient than the status quo strategy, requiring 129 ~ 656 fewer screenings per lung cancer death avoided, and 0.5 ~ 28 fewer screenings per life-year gained. The cost-effectiveness of risk-based screening was further improved when individual adherence to screening improved and individuals quit smoking after being screened.
Risk-based screening strategies are more efficient in reducing lung cancer deaths and gaining life years compared to the status quo strategy. Risk-stratified screening intervals can potentially balance long-term benefit-harm trade-offs and improve the cost-effectiveness of lung cancer screenings.
低剂量计算机断层扫描（LDCT）年度筛查被推荐用于重度吸烟者。然而，鉴于 LDCT 筛查的潜在危害，是否所有个体都需要进行年度筛查存在疑问。本研究旨在探讨基于风险的筛查在重度吸烟者中的获益-危害和成本效益，并确定筛查的最佳风险阈值和风险分层筛查间隔。
我们在中国进行了一项比较成本效益分析，采用基于队列的马尔可夫模型，模拟了一个由 19146 名年龄在 50 岁至 74 岁之间、吸烟史至少 30 包年且目前吸烟或戒烟时间<15 年的重度吸烟者组成的肺癌筛查队列。共评估了 34 种基于风险的筛查策略，这些策略根据筛查资格和筛查间隔（1 年、2 年、3 年、一次性、不筛查）的不同风险组而有所不同，并与所有重度吸烟者的年度筛查（现状策略）进行了比较。分析从卫生服务角度进行，时间范围为 30 年。采用中国 2021 年国内生产总值（GDP）的三倍（242928 元人民币）作为每获得一个质量调整生命年（QALY）的意愿支付（WTP）阈值。
与现状策略相比，有 9 种基于风险的筛查策略被认为具有成本效益，其中有两种甚至实现了成本节约。最具成本效益的策略是对 5 年风险阈值≥1.70%的个体进行年度筛查，对 5 年风险阈值为 1.03%1.69%的个体进行两年一次筛查，对 5 年风险阈值<1.03%的个体进行三年一次筛查。该策略的增量净货币收益（iNMB）最高，为 1032 元人民币。所有基于风险的筛查策略均比现状策略更有效，每避免 1 例肺癌死亡需要的筛查次数减少 129656 次，每获得 1 个生命年需要的筛查次数减少 0.5~28 次。当个体对筛查的依从性提高且个体在筛查后戒烟时，基于风险的筛查的成本效益进一步提高。
与现状策略相比，基于风险的筛查策略在降低肺癌死亡人数和获得生命年数方面更有效。风险分层筛查间隔可以在平衡长期获益-危害权衡的同时，提高肺癌筛查的成本效益。
