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Conventional Computed Tomographic Calcium Scoring vs Full Chest CTCS for Lung Cancer Screening: A Cost-Effectiveness Analysis
Christopher W. Towe
Corresponding Author
ORCiD: https://orcid.org/0000-0002-3850-8040
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This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Pulmonary Medicine.
Background Conventional CTCS images the mid/lower chest for coronary artery disease (CAD). Because many CAD patients are also at risk for lung malignancy, CTCS often discovers incidental pulmonary nodules (IPN). CTCS excludes the upper chest, where malignancy is common. Full-chest CTCS (FCT) may be a cost-effective screening tool for IPN. Methods A decision tree was created to compare a FCT to CTCS in a hypothetical patient cohort with suspected CAD. (Figure) The design compares the effects of missed cancers on CTCS with the cost of working up non-malignant nodules on FCT. The model was informed by results of the National Lung Screening Trial and literature review, including the rate of malignancy among patients receiving CTCS and the rate of malignancy in upper vs lower portions of the lung. The analysis outcomes are Quality-Adjusted Life Year (QALY) and incremental cost-effectiveness ratio (ICER), which is generally considered beneficial when <$50,000/QALY. Results Literature review suggests that rate of IPNs in the upper portion of the lung varied from 47-76%. Our model assumed that IPNs occur in upper and lower portions of the lung with equal frequency. The model also assumes an equal malignancy potential in upper lung IPNs despite data that malignancy occurs 61-66% in upper lung fields. In the base case analysis, a FCT will lead to an increase of 0.03 QALYs comparing to conventional CTCS (14.54 vs 14.51 QALY, respectively), which translates into an QALY increase of 16 days. The associated incremental cost for FCT is $278 ($1,027 vs $748, FCT vs CTCS respectively. The incremental cost-effectiveness ratio (ICER) is $10,289/QALY, suggesting significant benefit. Sensitivity analysis shows this benefit increases proportional to the rate of malignancy in upper lung fields. Conclusion Conventional CTCS may be a missed opportunity to screen for upper lung field cancers in high risk patients. The ICER of FCT is better than screening for breast cancer screening (mammograms $80k/QALY) and colon cancer (colonoscopy $6k/QALY). Prospective studies are appropriate to define protocols for FCT.
Keywords
Lung cancer screening, conventional computed tomographic calcium scoring, full chest calcium scoring scan, cost-effectiveness analysis, coronary artery disease
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CURRENT STATUS: Published
Version 3
Posted 23 Dec, 2019
Published
On 06 Jul, 2020
No community comments so far
Editorial decision: Accept
On 13 Jan, 2020
Submission checks complete
On 20 Dec, 2019
No comments provided
Editorial decision: Minor revision
On 18 Dec, 2019
Editor assigned
On 16 Dec, 2019
Submission checks complete
On 15 Dec, 2019
Editor invited
On 15 Dec, 2019
No comments provided
Editorial decision: Major revision
On 08 Nov, 2019
Review #2 received
Received 07 Nov, 2019
Reviewer #2 agreed
On 24 Oct, 2019
Review #1 received
Received 14 Oct, 2019
Reviewer #1 agreed
On 27 Aug, 2019
Reviewers invited
Invitations sent on 18 Aug, 2019
Submission checks complete
On 24 Jul, 2019
Editor assigned
On 16 Jul, 2019
First submitted
On 15 Jul, 2019
Editor invited
On 15 Jul, 2019
Metrics
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PDF Downloads: ...
HTML Views: ...
Subject Areas
Pulmonology
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This preprint is under consideration at BMC Pulmonary Medicine. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
Conventional Computed Tomographic Calcium Scoring vs Full Chest CTCS for Lung Cancer Screening: A Cost-Effectiveness Analysis
Christopher W. Towe
Corresponding Author
ORCiD: https://orcid.org/0000-0002-3850-8040
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
Version 3
Posted 23 Dec, 2019
Published
On 06 Jul, 2020
No community comments so far
Editorial decision: Accept
On 13 Jan, 2020
Submission checks complete
On 20 Dec, 2019
No comments provided
Editorial decision: Minor revision
On 18 Dec, 2019
Editor assigned
On 16 Dec, 2019
Submission checks complete
On 15 Dec, 2019
Editor invited
On 15 Dec, 2019
No comments provided
Editorial decision: Major revision
On 08 Nov, 2019
Review #2 received
Received 07 Nov, 2019
Reviewer #2 agreed
On 24 Oct, 2019
Review #1 received
Received 14 Oct, 2019
Reviewer #1 agreed
On 27 Aug, 2019
Reviewers invited
Invitations sent on 18 Aug, 2019
Submission checks complete
On 24 Jul, 2019
Editor assigned
On 16 Jul, 2019
First submitted
On 15 Jul, 2019
Editor invited
On 15 Jul, 2019
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Pulmonology
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Pulmonary Medicine.
Background Conventional CTCS images the mid/lower chest for coronary artery disease (CAD). Because many CAD patients are also at risk for lung malignancy, CTCS often discovers incidental pulmonary nodules (IPN). CTCS excludes the upper chest, where malignancy is common. Full-chest CTCS (FCT) may be a cost-effective screening tool for IPN. Methods A decision tree was created to compare a FCT to CTCS in a hypothetical patient cohort with suspected CAD. (Figure) The design compares the effects of missed cancers on CTCS with the cost of working up non-malignant nodules on FCT. The model was informed by results of the National Lung Screening Trial and literature review, including the rate of malignancy among patients receiving CTCS and the rate of malignancy in upper vs lower portions of the lung. The analysis outcomes are Quality-Adjusted Life Year (QALY) and incremental cost-effectiveness ratio (ICER), which is generally considered beneficial when <$50,000/QALY. Results Literature review suggests that rate of IPNs in the upper portion of the lung varied from 47-76%. Our model assumed that IPNs occur in upper and lower portions of the lung with equal frequency. The model also assumes an equal malignancy potential in upper lung IPNs despite data that malignancy occurs 61-66% in upper lung fields. In the base case analysis, a FCT will lead to an increase of 0.03 QALYs comparing to conventional CTCS (14.54 vs 14.51 QALY, respectively), which translates into an QALY increase of 16 days. The associated incremental cost for FCT is $278 ($1,027 vs $748, FCT vs CTCS respectively. The incremental cost-effectiveness ratio (ICER) is $10,289/QALY, suggesting significant benefit. Sensitivity analysis shows this benefit increases proportional to the rate of malignancy in upper lung fields. Conclusion Conventional CTCS may be a missed opportunity to screen for upper lung field cancers in high risk patients. The ICER of FCT is better than screening for breast cancer screening (mammograms $80k/QALY) and colon cancer (colonoscopy $6k/QALY). Prospective studies are appropriate to define protocols for FCT.
Figure 1
Figure 2