Cost Effectiveness of CT Screening in the National Lung Screening Trial William C. Black, M.D. Dartmouth-Hitchcock Medical Center NLST CEA Writing Team

Writing Team William C. Black, MDDartmouth-Hitchcock Medical Center Ilana F. Gareen, PhDBrown School of Public Health Samir S. Soneji, PhDDartmouth-Hitchcock Medical Center JoRean D. Sicks, MSBrown School of Public Health Emmett B. Keeler, PhDPardee RAND Graduate School Denise R. Aberle, MDUniversity of California at UCLA Arash Naeim, MDUniversity of California at UCLA Timothy R. Church, PhD, MSUniversity of Minnesota School of Public Health Gerard A. Silvestri, MD, MSMedical University of South Carolina Jeremy Gorelick, PhDBrown School of Public Health Constantine Gatsonis, PhDBrown School of Public Health

Outline Methods Base case results Subset & sensitivity analyses Limitations

Cost Effectiveness Analysis Comparison: LDCT, CXR, No Screen Health effects: LYs and QALYs Costs: $US (reference 2009) Perspective: Societal Time horizon: Within-trial and lifetime Discount rate: 3% Gold et al. Cost-effectiveness in health and medicine

Study Population CTCXRTotal All participants in full NLST26,72226,73053,452 Lost to FU within 1 day Missing lung ca information Less than 50 years of age112 All participants in NLST CEA26,64226,66053,302

Study Population CTCXRTotal All participants in NLST CEA26,64226,66053,302 With lung cancer diagnosis1, ,054 Deaths from lung cancer ,021 Deaths from other causes1,4511,4922,943

Health Effects (LYs) Aggregate LYs from entry to death Observed survival thru12/31/2009 Projected survival after 12/31/2009 –age, sex, smoking, lung ca stage

Health Effects (QALYs) Adjust LYs for QOL SF-6D utility scoring (0-1.0) Estimate missing scores –age, sex, lung ca stage Brazier et al. JHE 2002; 21:271-92

Costs Direct medical - screening, workup, treatment Non-medical - travel, lost wages

Direct Medical Costs Utilization based on medical abstraction Costs from utilization & Medicare prices Missing costs imputed using trial-wide variables – arm, scr result, lung ca, etc

Uncertainty Bootstrap confidence intervals Subset analyses Sensitivity analyses –Eff’ness CXR, # catch up cases, costs

Base Case Assumptions LDCT screening affects only lung cancer CXR screening has no effect No remaining catch up lung cancers.

Base Case Results STRATEGY$LYs∆$∆$∆LYs$/LY LDCT CXR NO SCR

Base Case Results STRATEGY$QALYs∆$∆$∆QALYs$/QALY LDCT CXR NO SCR

Bootstrap CIs Mean2.5%97.5% ∆$ ∆LYs ∆QALYs ∆$/LY ∆$/QALY 10,000 iterations

Subset Analysis Subset# subjects ∆$∆$ ∆ QALYs $/QALY Gender Men Women Age

Subset Analysis Subset# subjects ∆$∆$ ∆ QALYs $/QALY Smok status Former Current Lung ca risk 1 st quintile 2 nd quintile 3 rd quintile 4 th quintile 5 th quintile

CXR vs No Screening

Catch up in CXR arm

Impact of Positive Screen

Impact of Stage IA NSCLC

Cost of LDCT

Number of FU CTs

Cost of Incidental Findings

Relative Risk of Lung Cancer

LIMITATIONS Other effects of LDCT screening Survival Stage IA NCSLC Imprecision of QOL instruments Cost of screening process

SUMMARY NLST LDCT Scr ≈ _ Some uncertainty within NLST Much uncertainty outside NLST Opportunity to improve on NLST