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Original Investigation
October 21, 2021

Cost-effectiveness Evaluation of the 2021 US Preventive Services Task Force Recommendation for Lung Cancer Screening

Author Affiliations
  • 1Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston
  • 2Erasmus Medical Center, Rotterdam, the Netherlands
  • 3Department of Epidemiology, University of Michigan, Ann Arbor
  • 4Feinstein Institute for Medical Research, Northwell Health, New York, New York
  • 5Department of Radiology, Massachusetts General Hospital, Boston
  • 6Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
  • 7Division of General Internal Medicine, Department of Medicine, Mount Sinai Hospital, New York, New York
  • 8Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California
  • 9Department of Biomedical Data Sciences, Stanford University, Stanford, California
JAMA Oncol. Published online October 21, 2021. doi:10.1001/jamaoncol.2021.4942
Key Points

Question  Is the 2021 US Preventive Services Task Force (USPSTF) recommendation on lung cancer screening cost-effective?

Findings  In this economic evaluation of the cost-effectiveness of the 2021 USPSTF recommendation on lung cancer screening, a comparative modeling analysis found that relative to the 2013 USPSTF recommendation, the 2021 recommendation was cost-effective despite the expansion of screening eligibility to include younger smokers and those who had at least 20 pack-years of smoking exposure. However, alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years but expanded screening eligibility to former smokers who had not smoked for more than 15 years were estimated to be more cost-effective than the 2021 USPSTF recommendation.

Meaning  This study found that the 2021 USPSTF recommendation for lung cancer screening was cost-effective relative to the 2013 USPSTF recommendation but that expanding screening eligibility to include former smokers who have not smoked for more than 15 years might further improve the cost-effectiveness of the screening program and warrants further evaluation.

Abstract

Importance  The US Preventive Services Task Force (USPSTF) issued its 2021 recommendation on lung cancer screening, which lowered the starting age for screening from 55 to 50 years and the minimum cumulative smoking exposure from 30 to 20 pack-years relative to its 2013 recommendation. Although costs are expected to increase because of the expanded screening eligibility criteria, it is unknown whether the new guidelines for lung cancer screening are cost-effective.

Objective  To evaluate the cost-effectiveness of the 2021 USPSTF recommendation for lung cancer screening compared with the 2013 recommendation and to explore the cost-effectiveness of 6 alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years and an ending age for screening of 80 years but varied the starting ages for screening (50 or 55 years) and the number of years since smoking cessation (≤15, ≤20, or ≤25).

Design, Setting, and Participants  A comparative cost-effectiveness analysis using 4 independently developed microsimulation models that shared common inputs to assess the population-level health benefits and costs of the 2021 recommended screening strategy and 6 alternative screening strategies compared with the 2013 recommended screening strategy. The models simulated a 1960 US birth cohort. Simulated individuals entered the study at age 45 years and were followed up until death or age 90 years, corresponding to a study period from January 1, 2005, to December 31, 2050.

Exposures  Low-dose computed tomography in lung cancer screening programs with a minimum cumulative smoking exposure of 20 pack-years.

Main Outcomes and Measures  Incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) of the 2021 vs 2013 USPSTF lung cancer screening recommendations as well as 6 alternative screening strategies vs the 2013 USPSTF screening strategy. Strategies with a mean ICER lower than $100 000 per QALY were deemed cost-effective.

Results  The 2021 USPSTF recommendation was estimated to be cost-effective compared with the 2013 recommendation, with a mean ICER of $72 564 (range across 4 models, $59 493-$85 837) per QALY gained. The 2021 recommendation was not cost-effective compared with 6 alternative strategies that used the 20 pack-year criterion. Strategies associated with the most cost-effectiveness included those that expanded screening eligibility to include a greater number of former smokers who had not smoked for a longer duration (ie, ≤20 years and ≤25 years since smoking cessation vs ≤15 years since smoking cessation). In particular, the strategy that screened former smokers who quit within the past 25 years and began screening at age 55 years was associated with screening coverage closest to that of the 2021 USPSTF recommendation yet yielded greater cost-effectiveness, with a mean ICER of $66 533 (range across 4 models, $55 693-$80 539).

Conclusions and Relevance  This economic evaluation found that the 2021 USPSTF recommendation for lung cancer screening was cost-effective; however, alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years but included individuals who quit smoking within the past 25 years may be more cost-effective and warrant further evaluation.

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