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Cost-effectiveness decision analysis of mass screening for lung cancer |
Baba Y, Takahashi M, Tominguchi S, Kiyota S |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The use of chest radiographs for screening a middle aged population for lung cancer.
Economic study type Cost-effectiveness analysis.
Study population Asymptomatic male and female patients aged over 40 years old undergoing lung cancer screening in Japan.
Setting Community. The economic study was carried out in Kumamoto, Japan.
Dates to which data relate The effectiveness data were taken from a trial undertaken between 1991 -1994 and from studies and models previously published between 1990-1995. Cost data were derived from a study published in 1988. The price year was not explicitly stated.
Source of effectiveness data The evidence for the effectiveness of the intervention came from a single study, whilst the evidence for the effectiveness of the comparator (no screening) came from previously published sources.
Link between effectiveness and cost data The costing was undertaken retrospectively on the same patient sample as that used in the effectiveness study.
Study sample No power calculations to determine the sample size were reported. The intervention group consisted of 386,346 asymptomatic male and female patients over 40 years old who underwent lung cancer screening in Japan during the period 1991 - 1994. Randomisation was not undertaken.
Study design This was a prospective case series (each individual was his/her own control), performed in a single centre. 61 patients who underwent the first stage of the screening programme and were believed to have cancer, subsequently refused further examinations and treatment and were excluded from the analysis.
Analysis of effectiveness The analysis of effectiveness was based on treatment completers. The primary health outcome was the lung cancer status of each patient.
Effectiveness results Lung cancer screening via chest radiographs led to further investigations in 8,112 patients. Chest CT examinations found 264 cases of lung cancer. The actual 5-year survival rate for patients with mass screening detected lung cancer was 40.3%.
Clinical conclusions A programme of mass screening for lung cancer employing chest radiographs followed by chest CT examinations in those suspected of having cancer can detect lung cancer in its early stages.
Modelling A decision tree was used to model the costs and consequences of the screening programme compared with no screening. The model was analysed for a cohort of 386,346 patients who underwent lung cancer screening in Japan between 1991-94.
Outcomes assessed in the review The following parameters were obtained from the literature: 5 year survival rates for incidentally detected cases; prevalence of lung cancer within the study population; risk of death from radiation induced malignancies. These parameters are used within the model to determine the effectiveness of screening compared with no screening in terms of lives saved.
Study designs and other criteria for inclusion in the review Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Number of primary studies included Three studies were included in the review. 5 year survival rates for screen detected and incidentally detected cancer and the risk of death from radiation came from previously published studies; prevalence data came from a national data source.
Methods of combining primary studies Investigation of differences between primary studies Results of the review The 5 year survival rate for incidentally detected lung cancer was reported as 15%. The prevalence of lung cancer within the cohort was given as 0.099% and the loss of life from radiation induced secondary cancers was reported as 0.42 lives per 100,000 persons screened.
Measure of benefits used in the economic analysis The measures of benefits used within the analysis were tumours detected, lives saved, and life expectancy. Discounting was not undertaken.
Direct costs Costs were not discounted. Quantities and resources were reported separately. The costs of the initial chest radiography for all patients and chest CT in those suspected of having cancer were included within the analysis, as was the difference in the costs associated with treating a case of lung cancer detected through the screening programme and a case detected incidentally. The costs were provided per event, although resources are not detailed specifically. The quantity/cost boundary adopted was that of the third party provider. The estimation of costs was based on actual data. The resource quantities were derived from the study for the intervention and generated by the model for the comparator. The price year was not given.
Statistical analysis of costs Sensitivity analysis The cost-effectiveness of a programme focused on screening older people was also calculated.
Estimated benefits used in the economic analysis The screening programme identified a total of 264 confirmed cases of lung cancer, and was estimated to make a net saving of 16.28 lives for every 100,000 individuals screened (lives saved = 16.7 per 100,000 and lives lost due to radiation exposure of screening = 0.42 per 100,000). The estimated number of lung tumours was 384. The gain in life expectancy associated with screening was 446.7 years per 100,000 men screened and 133.3 years per 100,000 women screened.
Cost results The cost of mass screening for lung cancer was estimated to be Y1,824 per person compared with no screening programme.
Synthesis of costs and benefits The screening programme was reported to cost Y2,669,284 per tumour identified and Y10,811,350 per life saved, both compared with no screening programme. When the screening programme was focused upon an older population (aged over 70 years old) the cost-effectiveness was reported as Y5,977,380 per life saved.
Authors' conclusions The authors concluded that there is a benefit associated with screening for lung cancer in a middle aged population, although the cost-effectiveness is high. The cost-effectiveness of screening can be reduced by focusing the programme upon an older population.
CRD COMMENTARY - Selection of comparators The reason for the choice of comparator is clear. You, as a user of this database, should consider whether these health technologies apply to your setting. Validity of estimate of measure of effectiveness The values for the parameters used within the model to generate the effectiveness measure were extracted from single studies. There is not enough information within the paper to justify such a selective approach. Potential biases may arise through differences between the study population and the populations used within the published studies. The estimate of 5 year survival rates for screen detected cases of lung cancer may be subject to both lead time bias and length bias. Validity of estimate of costs Resource quantities are reported separately from prices. Few details are provided concerning the source of the cost information, although the quantities were derived from a single study for the intervention and were generated by the model for the comparator. The costs may be inappropriate for use within the NHS. Important cost items do not appear to have been omitted. No sensitivity analysis was undertaken concerning costs. Other issues The issue of generalisability to other settings or countries has not been addressed. Appropriate comparisons with other studies were not made. There is, however, no evidence of selective presentation of the results. Appropriate use was made of modelling to evaluate the cost-effectiveness of screening versus no screening. Generally the origins of information within the paper are difficult to ascertain and aspects of the calculations are difficult to follow. Bibliographic details Baba Y, Takahashi M, Tominguchi S, Kiyota S. Cost-effectiveness decision analysis of mass screening for lung cancer. Academic Radiology 1998; 5(Supplement 2): S344-S346 Other publications of related interest 1. Sobue T, Suzuki T, Naruke T. The Japanese Lung-Cancer-Screening Research Group: a case-control study for evaluating lung-cancer screening in Japan. International Journal of Cancer 1992;50:230-237.
2. Linuma T, Tateno Y. Cost-effective analysis of mass screening for lung cancer. Nippon Acta Radiologica 1988;48:1342-1348.
3. Linuma T, Tateno Y, Matsumoto T. Comparison of two types of mass screening for lung cancer in terms of cost-effectiveness: indirect chest X-ray vs LSCT. Nippon Acta Radiologica 1994;54:943-949.
Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Cost-Benefit Analysis; Costs and Cost Analysis; Female; Humans; Lung Neoplasms /economics /radiography; Male; Mass Screening /economics; Middle Aged; Quality-Adjusted Life Years; Radiography, Thoracic /economics AccessionNumber 21998001325 Date bibliographic record published 31/10/1999 Date abstract record published 31/10/1999 |
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