Cost-effectiveness evaluation of the 2021 US Preventive Services Task Force recommendation for lung cancer screening

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.Accepted manuscrip

Enhancing the Impact of Lung Cancer Screening: Assessment of the Performance of Joint Smoking Cessation and Screening Interventions and Personalized Screening Scheduling Using Microsimulation Modeling

Lung cancer is the deadliest cancer in the United States. Low-dose computed tomography for lung cancer screening has proven effective in reducing lung cancer mortality and is thus recommended for ever smokers with a considerable smoking history. This dissertation investigated two strategies to refine lung cancer screening (LCS) processes: smoking cessation intervention in the context of LCS and optimal screening schedules for LCS. I utilized a microsimulation modeling approach to quantify the benefits, harms, and costs of various strategies. I considered the screening eligibility criteria under the 2013 US Preventive Services Task Force guidelines: smokers between ages 55 and 80, smoked for at least 30 pack years and former smokers quit within 15 years. First, I extended the University of Michigan Lung Cancer Natural History and Screening (MichiganLung) model, an established microsimulation model, to compare the effects on mortality of a hypothetical one-time cessation intervention at the first annual screening vs. annual screening alone. I tested the sensitivity of results to different assumptions about screening uptake and cessation efficacy. Across all assumptions, adding a smoking cessation intervention to screening reduced lung cancer mortality and overall deaths compared to screening alone. Our results show that smoking cessation interventions would clearly enhance the net benefits of LCS programs. Second, in collaboration with colleagues from the National Cancer Institute Smoking Cessation at Lung Examination Consortium, we conducted a cost-effectiveness analysis for cessation interventions at the first screen plus annual screening using the MichiganLung model. We considered five cessation interventions, including pharmacotherapy only, or pharmacotherapy with web-based, telephone, individual, or group counseling. Cost-effective cessation strategies included pharmacotherapy with web-based, telephone, or individual counseling. All smoking cessation interventions delivered with LCS were likely to reduce lung cancer mortality and result in life-years gained at reasonable costs. The choice of cessation intervention for screening clinics should be guided by practical concerns such as staff training and availability. Third, although annual LCS is currently recommended, a less intensive schedule may be preferable for low-risk individuals. I utilized a risk-threshold method to determine optimal screening schedules based on individual lung cancer risk, past screening results and other risk factors. Using the MichiganLung model, I compared lung cancer outcomes from adaptive screening schedules to regular (non-adaptive) triennial, biennial, and annual screenings. Adaptive screening schedules had a better benefit-to-harm ratio and were more efficient than regular screening schedules. Individual lung cancer risk and preferences play an important role in the performance of LCS. These findings support the adoption of patient-centered decision-making processes and individualized LCS strategies. Finally, I evaluated the cost-effectiveness of adaptive and regular (non-adaptive) schedules for LCS using the MichiganLung model results. I identified 9 dominant strategies, with 8 being adaptive schedules while 1 being annual screening. Compared with no screening scenario, all strategies had a cost to QALY ratio under $50,000. Compared incrementally, seven out of the eight dominant adaptive schedules were cost-effective under the$100,000 willingness-to-pay threshold, whereas annual screening had an incremental cost to QALY ratio over $120,000. Hence, under a fixed budget healthcare system, adaptive schedules may provide better “value for the money.” Overall, this dissertation identified two strategies that could enhance the impact of LCS by maximizing the net benefits and cost-effectiveness. It furthermore demonstrates the potential for mathematical modeling to translate risk estimates and other epidemiological data into clinically meaningful recommendations.PHDEpidemiological ScienceUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/169799/1/caop_1.pd

Age, period and cohort trends in smoking in Mexico, 2000-2016

Background Mexico has one of the most substantial burden of tobacco-related illnesses in the world where smoking causes more than 60000 deaths per year in the country. Examining smoking patterns for different birth cohorts would provide valuable insight into the impact of tobacco control policies. Methods Using smoking data for adults (age>=20) from Encuesta Nacional de Salud (National Health Survey; 2000) and Encuesta Nacional de Salud y Nutricion (National Health and Nutrition Surveys: 2006, 2012, 2016), we evaluated smoking trends by gender through age-period-cohort models with restricted cubic splines. Specifically, temporal effects by age, period, and birth cohort (1905-1990) on the prevalence of ever and current smoking were estimated. In combination with these estimates, a methodology developed by the Cancer Intervention and Surveillance Modeling Network Lung group is used to reconstruct smoking histories by cohort and gender for Mexico population based on these cross-sectional surveys. Results As expected, levels of ever and current smoking prevalence are higher for men compared to women. The prevalence of ever smokers has been decreasing in both sexes across all birth cohorts, with a sharper rate of decrease for women. Current smoking prevalence has also been declining in both sexes across all birth cohorts. The rates of decrease for current smoking differ between men and women, however; the prevalence of current smokers in men decreased at a faster rate for cohorts born before 1960 compared to women. Moreover, current smoking has been decreasing across all ages in both men and women. Conclusions This is the first attempt to study smoking trends in Mexico using age-period-cohort models. The resulting estimates will help us reconstruct smoking histories, shedding light on patterns of smoking initiation and cessation in the population over time. Together, this information could inform tobacco control interventions to decrease the burden of tobacco-related illnesses in the country

Comparison of Cholangiocarcinoma and Hepatocellular Carcinoma Incidence Trends from 1993 to 2012 in Lampang, Thailand

Liver cancer is the most common cancer in Northern Thailand, mainly due to the dietary preference for raw fish, which can lead to infection by the parasite, O. viverrini, a causal agent of cholangiocarcinoma. We conducted a temporal trend analysis of cross-sectional incidence rates of liver cancer in Lampang, Northern Thailand. Liver cancer data from 1993–2012 were extracted from Lampang Cancer Registry. The multiple imputation by chained equations method was used to impute missing histology data. Imputed data were analyzed using Joinpoint and age-period-cohort (APC) models to characterize the incidence rates by gender, region, and histology, considering hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA). We observed a significant annual increase in CCA incidence and a considerable decrease in HCC incidence for both genders in Lampang. The APC analysis suggested that CCA incidence rates were higher in older ages, younger cohorts, and later years of diagnosis. In contrast, HCC incidence rates were higher in older generations and earlier years of diagnosis. Further studies of potential risk factors of CCA are needed to better understand and address the increasing burden of CCA in Lampang. Our findings may help to draw public attention to cholangiocarcinoma prevention and control in Northern Thailand

Smoking disparities by level of educational attainment in the United States, 1966 to 2015

Background Previous studies in the U.S. show higher smoking rates among those with lower levels of education attainment. Less is known about how these smoking patterns vary by birth cohort or how they may be driven by different demographic profiles across education groups. Furthermore, limited attention has been given to differences in smoking behaviors between those with less than a high school degree and those with 8th grade education or less. Methods Data from the National Health Interview Survey 1966-2015 were utilized to obtain smoking-related information for U.S. adults aged 25 years or older. We developed age-period-cohort models with constrained natural splines to estimate smoking prevalence in groups categorized with five education levels: ≤8th grade, 9-11th grade, high school graduate or GED, some college, and at least a college degree. Annual probabilities of smoking initiation, cessation and intensity by age, birth cohort (1890-1990), gender, and education level were also estimated by the models. Additional regression analyses were conducted to identify sociodemographic factors that may explain smoking disparities across education subgroups. Results The probability of smoking initiation was highest among individuals with 9-11 th grade education and lowest among those with a college degree or more. The initiation probability among those with ≤8 th grade education decreased by birth cohort, resulting in this group having the second lowest smoking prevalence after those with a college degree or more in more recent birth cohorts. The smoking cessation probability was highest among those with a college degree or more. Additional analyses suggest that the low smoking rates among those with ≤8 th grade education may be driven by the increasing proportion of non-US born Hispanics in this group. Conclusions This study identifies population characteristics that may be driving smoking disparities between levels of educational attainment, providing detailed insights into change in smoking patterns by education for different U.S. birth cohorts

Comparing the Corrosion Resistance of 5083 Al and Al₂O₃3D/5083 Al Composite in a Chloride Environment

In this study, an Al2O33D/5083 Al composite was fabricated by infiltrating a molten 5083 Al alloy into a three-dimensional alumina reticulated porosity ceramics skeleton preform (Al2O33D) using a pressureless infiltration method. The corrosion resistance of 5083 Al alloy and Al2O33D/5083 Al in NaCl solution were compared via electrochemical impedance spectroscopy (EIS), dynamic polarization potential (PDP), and neutral salt spray (NSS) tests. The microstructure of the two materials were investigated by 3D X-ray microscope and scanning electron microscopy aiming at understanding the corrosion mechanisms. Results show that an Al2O33D/5083 Al composite consists of interpenetrating structure of 3D-continuous matrices of continuous networks 5083 Al alloy and Al2O33D phase. A large area of strong interfaces of 5083 Al and Al2O33D exist in the Al2O33D/5083 Al composite. The corrosion development process can be divided into the initial period, the development period, and the stability period. Al2O33D used as reinforcement in Al2O33D/5083 Al composite improves the corrosion resistance of Al2O33D/5083 Al composite via electrochemistry tests. Thus, the corrosion resistance of Al2O33D/5083 Al is higher than that of 5083 Al alloy. The NSS test results indicate that the corrosion resistance of Al2O33D/5083 Al was lower than that of 5083 Al alloy during the initial period, higher than that of 5083 Al alloy during the development period, and there was no obvious difference in corrosion resistance during the stability period. It is considered that the elements in 5083 Al alloy infiltrated into the Al2O33D/5083 Al composite are segregated, and the uniform distribution of the segregated elements leads to galvanic corrosion during the corrosion initial period. The perfect combination of interfaces of Al2O33D and the 5083 Al alloy matrix promotes excellent corrosion resistance during the stability period

Risk Model-Based Lung Cancer Screening: A Cost-Effectiveness Analysis

BACKGROUND: In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model-based strategies), highlighting the need for further research on the benefits and harms of risk model-based screening. OBJECTIVE: To evaluate and compare the cost-effectiveness of risk model-based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds. DESIGN: Comparative modeling analysis. DATA SOURCES: National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator. TARGET POPULATION: 1960 U.S. birth cohort. TIME HORIZON: 45 years. PERSPECTIVE: U.S. health care sector. INTERVENTION: Annual low-dose computed tomography in risk model-based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model. OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost. RESULTS OF BASE-CASE ANALYSIS: Risk model-based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2$94 659 (model range, $72 639 to$156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%). RESULTS OF SENSITIVITY ANALYSES: Risk model-based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions. LIMITATION: Risk models were restricted to age, sex, and smoking-related risk predictors. CONCLUSION: Risk model-based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration. PRIMARY FUNDING SOURCE: National Cancer Institute (NCI)