Lung Cancer Screening
2002; Elsevier BV; Volume: 121; Issue: 5 Linguagem: Inglês
10.1378/chest.121.5.1388
ISSN1931-3543
Autores Tópico(s)Esophageal Cancer Research and Treatment
ResumoThe recent Enron scandal illustrates how creative accounting practices can be used by self- interested parties to make ledger columns dance to favored music. One fact that all medical accountants can agree on is that mass screening for lung cancer (LC) using low-dose, noncontrast, spiral, CT scanning (LDCT) will be very, very expensive. Precisely how expensive, whether it will be worthwhile, and who will pay are matters of bitter contention. Widely variant estimates of cost and cost-effectiveness will be published in this and future issues of CHEST.In essence, the math is simple. One must determine who to screen, what percentage will consent to be screened, and what the initial CT scan and any further diagnostic tests will cost. Extrapolation provides the national cost. The calculation of cost and survival before and after the implementation of mass screening will provide figures for relative cost- effectiveness.The problem is that although we know some of the numbers to plug into these equations, others must be estimated or predicted. Hence, the opportunity for creative accounting; hence, the marked disparity of results in different publications.Zero dollars are currently spent on LC screening. What is the cost of this policy? The current direct medical costs incurred in the treatment of tobacco-related disease in the United States total at least $50 billion,1Warner KE Hodgson TA Carroll CE Medical costs of smoking in the United States: estimates, their validity and their implications.Tob Control. 1999; 8: 290-300Crossref PubMed Scopus (130) Google Scholar increasing to $123 billion when indirect costs are included. Since 37% of deaths caused by tobacco smoking (160,000 of 430,000 deaths) are due to LC, I will assume $18.5 billion in direct costs and $45.5 billion in total costs attributable to LC. As a return on this expenditure, 23,660 individuals (ie, 14% of LC patients) survive at least 5 years2Jemal A Thomas A Taylor M et al.Cancer statistics 2002.CA Cancer J Clin. 2002; 52: 23-47Crossref PubMed Scopus (2915) Google Scholar at a direct cost of $781,910 and a total cost of $1,923,076 per survivor. The remaining 160,000 patients suffer and die.The calculations for screening are more complex. There are currently an estimated 93 million smokers and ex-smokers in the United States. Should they all be screened? Less than 1,000 LC cases are seen in patients who are < 40 years of age in the United States annually. I have chosen age 45 years as a lower limit because of the way that the National Institutes of Health calculates the percentage of the population by age. Survival and cost-effectiveness data indicate that screening above age 75 years provides limited benefit, and so I have assumed that screening will not be performed in patients who are older than that age.3Marshall D Simpson KN Earle CC et al.Economic decision analysis model of screening for lung cancer.Eur J Cancer. 2001; 37: 1759-1767Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar There are 79,391,757 men and women in the United States between 45 and 74 years of age.4US Census Bureau QT-01 Profile of General Demographic Characteristics.Available at: http://factfinder.census.gov/servlet/QTTable?ds_name = D&geo_id = D&qr_ name = ACS_C2SS_EST_G00_QT01&_lang = enDate: 2000Google ScholarSince 75% of men and 50% of women are ever-smokers,5Thun MJ Day-Lally C Myers DG et al.Trends in tobacco smoking and mortality from cigarette use in cancer prevention studies I (1959 through 1965) and II (1982 through 1988).in: Smoking and tobacco control (chapter 4): changes in cigarette-related disease and their implication for prevention and control (monograph 8). National Institutes of Health, National Cancer Institute, Bethesda, MDFebruary 1997Google Scholar the number of screening candidates is reduced to no more than 50,000,000. There is then the question of what constitutes a high-risk group from the standpoint of tobacco carcinogen exposure. Not all candidates will have had exposure to the chosen minimal exposure (ie, 10 pack-years). Further reductions are required to reflect those persons who will not present for screening or will not be compliant in subsequent years. The prevalence of screening is approximately 65% for mammography and 85% for Pap smears.6Smith RA Cokkinides V von Eschenbach AC et al.American Cancer Society guidelines for the early detection of cancer.CA Cancer J Clin. 2002; 52: 8-22Crossref PubMed Scopus (363) Google ScholarSince tobacco smoking causes not only LC, but also coronary artery disease, cerebrovascular disease and peripheral vascular disease, chronic bronchitis and emphysema, cancers in other organs, and many other serious illnesses, many candidates have too much comorbidity to benefit from the treatment of LC. Accordingly, I assume that the maximum number for persons screened would not surpass 25,000,000.The price of an LDCT in Southern California at present is $300 (a bilateral mammogram costs $106). Since this price depends on the cost of the equipment and the time required for an individual examination, it can reasonably be expected to come down in price with wider application in response to competitive market forces.Assuming that, in the first year, all 25 million persons are screened (a highly unlikely scenario) at $300 each, the maximal cost of the initial screening examination would be $7.5 billion. Because many of those screened will have nodules detected, there will be further expense for tests to confirm or exclude LC. The Early Lung Cancer Action Project study7Henschke CI McCauley DI Yankelevitz DF et al.Early Lung Cancer Action Project: overall design and findings from baseline screening.Lancet. 1999; 354: 99-105Abstract Full Text Full Text PDF PubMed Scopus (2143) Google Scholar found 23% of persons had nodules that required further workup (ie, 5,750,000 study subjects nationally). Such persons require follow-up with high-resolution, contrast CT scans (approximate cost, $500 per scan) on two to four occasions. A small percentage of persons will require transthoracic needle biopsies or surgical resection for diagnosis. Assuming that the average cost of this workup will be $2,000, the total cost of a subsequent workup would be $11.5 billion. The maximum total cost for the first year thus would be $19 billion. In subsequent years, fewer new nodules would be discovered, and old nodules would have been demonstrated to be benign.8Henschke CI Naidich DP Yankelevitz DF et al.Early Lung Cancer Action Project: initial findings on repeat screenings.Cancer. 2001; 92: 153-159Crossref PubMed Scopus (453) Google Scholar Thus, the downstream reduction in cost would be considerable. Treatment dollars would be spent on an intervention (ie, surgical resection) that can reasonably be expected to result in an increase in survival rate and a reduction in mortality rate in stage IA patients.One major economic benefit that can be anticipated is a reduction in multimodality treatment costs in screened patients. Patients with stage IA LC require treatment only with surgical resection at a cost of $20,000 to $30,000 per case. Among cases of LC, 75 to 80% are now discovered in stages III and IV,9Kosary CL Gloeckler Reis LA Miller BA et al.SEER cancer statistics review. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, Bethesda, MD1973–1992: 289Google Scholar for which different guidelines recommend radiation therapy and/or chemotherapy for curative or palliative treatment. Oncologist Paul Bunn, MD, during a lecture at a City of Hope symposium (Las Vegas, NV; April 2001), stated that the cost of the best available regimen of chemotherapy is $43,000. It is known that approximately 30% of LC patients in the United States receive chemotherapy. Therefore, we can estimate a cost of approximately $2.3 billion, with few patients attaining long-term survival.In this issue of CHEST (see page 1507), Robert A. Clark, MD, and his colleagues at the H. Lee Moffit Cancer Center have presented a well-conceived and innovative model of data analysis that has very important implications for public health policy in the United States. Their approach is interesting. Rather than guesstimate numbers to plug into their equations, they calculate a broad range of figures over a wide spectrum of possible results. They show considerable restraint by adopting only the most conservative “worst-case” estimates of potential costs and benefits. They appear to have bent over backward to anticipate and forestall potential criticism from opponents of LC screening. Their estimates are so pessimistic, in fact, that a separate economic analysis based on more optimistic cost and cost-effectiveness projections will be needed. The take-home point from their analysis, however, is very compelling. Even when one assumes worst-case results, LDCT should prove to be cost-effective. There is a very real possibility that LC screening, despite a high initial cost, can save money as well as lives. This possibility must be investigated immediately in carefully designed trials so that further millions of people need not suffer and die.Where will the money to pay for screening trials come from? Medicare, Medicaid, managed-care companies, and health insurance companies will certainly not pay until data, public opinion, or both compel them to. Accordingly, only those who can afford to pay out of pocket can participate. One obvious source is funding from the Master Settlement Agreement between state attorneys general and the tobacco industry, but most of the $200 billion-plus is currently spent on pet political projects unrelated to tobacco control.10General Accounting Office Report to the Honorable John McCain, Ranking Minority Member, Committee on Commerce, Science, and Transportation, US Senate; June Tobacco Settlement; States Use of Master Settlement Agreement Payments. Government Printing Office, Washington, DCJune 2001Google Scholar In Los Angeles, the money is spent paving sidewalks. A second potential source is from a Justice Department RICO investigation of the tobacco industry that was initiated during the Clinton years, currently languishing under the Bush administration. Another obvious source of funding for LC screening is from class action lawsuits against the industry that is responsible for causing the disease through its premeditated, deceptive marketing of an addictive, carcinogenic product. Tobacco industry expert witnesses were recently successful in convincing a West Virginia jury in the first such trial that LC screening is not just ineffective, but is also dangerous.11Smith V Radiologist: lung-screen test smokers want is unproven, risky. Raleigh News & Observer.Available at http://www.newsobserver.com/ncwire/news/story/832527p-821857c.htmlDate: October 25, 2001Google Scholar The recent Enron scandal illustrates how creative accounting practices can be used by self- interested parties to make ledger columns dance to favored music. One fact that all medical accountants can agree on is that mass screening for lung cancer (LC) using low-dose, noncontrast, spiral, CT scanning (LDCT) will be very, very expensive. Precisely how expensive, whether it will be worthwhile, and who will pay are matters of bitter contention. Widely variant estimates of cost and cost-effectiveness will be published in this and future issues of CHEST. In essence, the math is simple. One must determine who to screen, what percentage will consent to be screened, and what the initial CT scan and any further diagnostic tests will cost. Extrapolation provides the national cost. The calculation of cost and survival before and after the implementation of mass screening will provide figures for relative cost- effectiveness. The problem is that although we know some of the numbers to plug into these equations, others must be estimated or predicted. Hence, the opportunity for creative accounting; hence, the marked disparity of results in different publications. Zero dollars are currently spent on LC screening. What is the cost of this policy? The current direct medical costs incurred in the treatment of tobacco-related disease in the United States total at least $50 billion,1Warner KE Hodgson TA Carroll CE Medical costs of smoking in the United States: estimates, their validity and their implications.Tob Control. 1999; 8: 290-300Crossref PubMed Scopus (130) Google Scholar increasing to $123 billion when indirect costs are included. Since 37% of deaths caused by tobacco smoking (160,000 of 430,000 deaths) are due to LC, I will assume $18.5 billion in direct costs and $45.5 billion in total costs attributable to LC. As a return on this expenditure, 23,660 individuals (ie, 14% of LC patients) survive at least 5 years2Jemal A Thomas A Taylor M et al.Cancer statistics 2002.CA Cancer J Clin. 2002; 52: 23-47Crossref PubMed Scopus (2915) Google Scholar at a direct cost of $781,910 and a total cost of $1,923,076 per survivor. The remaining 160,000 patients suffer and die. The calculations for screening are more complex. There are currently an estimated 93 million smokers and ex-smokers in the United States. Should they all be screened? Less than 1,000 LC cases are seen in patients who are < 40 years of age in the United States annually. I have chosen age 45 years as a lower limit because of the way that the National Institutes of Health calculates the percentage of the population by age. Survival and cost-effectiveness data indicate that screening above age 75 years provides limited benefit, and so I have assumed that screening will not be performed in patients who are older than that age.3Marshall D Simpson KN Earle CC et al.Economic decision analysis model of screening for lung cancer.Eur J Cancer. 2001; 37: 1759-1767Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar There are 79,391,757 men and women in the United States between 45 and 74 years of age.4US Census Bureau QT-01 Profile of General Demographic Characteristics.Available at: http://factfinder.census.gov/servlet/QTTable?ds_name = D&geo_id = D&qr_ name = ACS_C2SS_EST_G00_QT01&_lang = enDate: 2000Google Scholar Since 75% of men and 50% of women are ever-smokers,5Thun MJ Day-Lally C Myers DG et al.Trends in tobacco smoking and mortality from cigarette use in cancer prevention studies I (1959 through 1965) and II (1982 through 1988).in: Smoking and tobacco control (chapter 4): changes in cigarette-related disease and their implication for prevention and control (monograph 8). National Institutes of Health, National Cancer Institute, Bethesda, MDFebruary 1997Google Scholar the number of screening candidates is reduced to no more than 50,000,000. There is then the question of what constitutes a high-risk group from the standpoint of tobacco carcinogen exposure. Not all candidates will have had exposure to the chosen minimal exposure (ie, 10 pack-years). Further reductions are required to reflect those persons who will not present for screening or will not be compliant in subsequent years. The prevalence of screening is approximately 65% for mammography and 85% for Pap smears.6Smith RA Cokkinides V von Eschenbach AC et al.American Cancer Society guidelines for the early detection of cancer.CA Cancer J Clin. 2002; 52: 8-22Crossref PubMed Scopus (363) Google Scholar Since tobacco smoking causes not only LC, but also coronary artery disease, cerebrovascular disease and peripheral vascular disease, chronic bronchitis and emphysema, cancers in other organs, and many other serious illnesses, many candidates have too much comorbidity to benefit from the treatment of LC. Accordingly, I assume that the maximum number for persons screened would not surpass 25,000,000. The price of an LDCT in Southern California at present is $300 (a bilateral mammogram costs $106). Since this price depends on the cost of the equipment and the time required for an individual examination, it can reasonably be expected to come down in price with wider application in response to competitive market forces. Assuming that, in the first year, all 25 million persons are screened (a highly unlikely scenario) at $300 each, the maximal cost of the initial screening examination would be $7.5 billion. Because many of those screened will have nodules detected, there will be further expense for tests to confirm or exclude LC. The Early Lung Cancer Action Project study7Henschke CI McCauley DI Yankelevitz DF et al.Early Lung Cancer Action Project: overall design and findings from baseline screening.Lancet. 1999; 354: 99-105Abstract Full Text Full Text PDF PubMed Scopus (2143) Google Scholar found 23% of persons had nodules that required further workup (ie, 5,750,000 study subjects nationally). Such persons require follow-up with high-resolution, contrast CT scans (approximate cost, $500 per scan) on two to four occasions. A small percentage of persons will require transthoracic needle biopsies or surgical resection for diagnosis. Assuming that the average cost of this workup will be $2,000, the total cost of a subsequent workup would be $11.5 billion. The maximum total cost for the first year thus would be $19 billion. In subsequent years, fewer new nodules would be discovered, and old nodules would have been demonstrated to be benign.8Henschke CI Naidich DP Yankelevitz DF et al.Early Lung Cancer Action Project: initial findings on repeat screenings.Cancer. 2001; 92: 153-159Crossref PubMed Scopus (453) Google Scholar Thus, the downstream reduction in cost would be considerable. Treatment dollars would be spent on an intervention (ie, surgical resection) that can reasonably be expected to result in an increase in survival rate and a reduction in mortality rate in stage IA patients. One major economic benefit that can be anticipated is a reduction in multimodality treatment costs in screened patients. Patients with stage IA LC require treatment only with surgical resection at a cost of $20,000 to $30,000 per case. Among cases of LC, 75 to 80% are now discovered in stages III and IV,9Kosary CL Gloeckler Reis LA Miller BA et al.SEER cancer statistics review. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, Bethesda, MD1973–1992: 289Google Scholar for which different guidelines recommend radiation therapy and/or chemotherapy for curative or palliative treatment. Oncologist Paul Bunn, MD, during a lecture at a City of Hope symposium (Las Vegas, NV; April 2001), stated that the cost of the best available regimen of chemotherapy is $43,000. It is known that approximately 30% of LC patients in the United States receive chemotherapy. Therefore, we can estimate a cost of approximately $2.3 billion, with few patients attaining long-term survival. In this issue of CHEST (see page 1507), Robert A. Clark, MD, and his colleagues at the H. Lee Moffit Cancer Center have presented a well-conceived and innovative model of data analysis that has very important implications for public health policy in the United States. Their approach is interesting. Rather than guesstimate numbers to plug into their equations, they calculate a broad range of figures over a wide spectrum of possible results. They show considerable restraint by adopting only the most conservative “worst-case” estimates of potential costs and benefits. They appear to have bent over backward to anticipate and forestall potential criticism from opponents of LC screening. Their estimates are so pessimistic, in fact, that a separate economic analysis based on more optimistic cost and cost-effectiveness projections will be needed. The take-home point from their analysis, however, is very compelling. Even when one assumes worst-case results, LDCT should prove to be cost-effective. There is a very real possibility that LC screening, despite a high initial cost, can save money as well as lives. This possibility must be investigated immediately in carefully designed trials so that further millions of people need not suffer and die. Where will the money to pay for screening trials come from? Medicare, Medicaid, managed-care companies, and health insurance companies will certainly not pay until data, public opinion, or both compel them to. Accordingly, only those who can afford to pay out of pocket can participate. One obvious source is funding from the Master Settlement Agreement between state attorneys general and the tobacco industry, but most of the $200 billion-plus is currently spent on pet political projects unrelated to tobacco control.10General Accounting Office Report to the Honorable John McCain, Ranking Minority Member, Committee on Commerce, Science, and Transportation, US Senate; June Tobacco Settlement; States Use of Master Settlement Agreement Payments. Government Printing Office, Washington, DCJune 2001Google Scholar In Los Angeles, the money is spent paving sidewalks. A second potential source is from a Justice Department RICO investigation of the tobacco industry that was initiated during the Clinton years, currently languishing under the Bush administration. Another obvious source of funding for LC screening is from class action lawsuits against the industry that is responsible for causing the disease through its premeditated, deceptive marketing of an addictive, carcinogenic product. Tobacco industry expert witnesses were recently successful in convincing a West Virginia jury in the first such trial that LC screening is not just ineffective, but is also dangerous.11Smith V Radiologist: lung-screen test smokers want is unproven, risky. Raleigh News & Observer.Available at http://www.newsobserver.com/ncwire/news/story/832527p-821857c.htmlDate: October 25, 2001Google Scholar
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