Cost-Effectiveness of an Organized Lung Cancer Screening Program for Asbestos-Exposed Subjects

Our plain-English summary of Cost-Effectiveness of an Organized Lung Cancer Screening Program for Asbestos-Exposed Subjects, by S. Gendarme, J.C. Pairon, P. Andujar, et al (Cancers, 2022).

The study

• Authors: S. Gendarme, J.C. Pairon, P. Andujar, F. Laurent, P. Brochard, F. Delva, B. Clin, A. Gislard, C. Paris, I. Thaon, H. Goussault, F. Canoui-Poitrine, C. Chouaïd
• Journal: Cancers
• Published: 2022;14(17)
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: The National Lung Screening Trial (NLST) and NELSON study opened the debate on the relevance of lung cancer (LC) screening in subjects exposed to occupational respiratory carcinogens. This analysis reported the incremental cost-effectiveness ratios (ICER) of an organized LC screening program for an asbestos-exposed population. Methods: Using Markov modelization, individuals with asbestos exposure were either monitored without intervention or annual low-dose thoracic computed-tomography (LDTCT) scan LC screening. LC incidence came from a prospective observational cohort of subjects with occupational asbestos exposure. The intervention parameters were those of the NLST study. Utilities and LC-management costs came from published reports. A sensitivity analysis evaluated different screening strategies. Results: The respective quality-adjusted life year (QALY) gain, supplementary costs and ICER [95% confidence interval] were: 0.040 [0.010-0.065] QALY, 6900 [3700-11,800] € and 170,000 [75,000-645,000] €/QALY for all asbestos-exposed subjects; and 0.144 [0.071-0.216] QALY, 13,000 [5700-26,800] € and 90,000 [35,000-276,000] €/QALY for smokers with high exposure. When screening was based on biennial LDTCT scans, the ICER was 45,000 [95% CI: 15,000-116,000] €/QALY. Conclusions: Compared to the usual ICER thresholds, biennial LDTCT scan LC screening for smokers with high occupational exposure to asbestos is acceptable and preferable to annual scans.

In plain English

This was a computer modelling study (a Markov model). It estimated the costs and health gains of lung cancer screening with low-dose CT scans for people with past work exposure to asbestos in France. Lung cancer rates came from the ARDCO cohort of 14,218 retired or unemployed workers in four French regions. Screening effects were taken from a US trial in smokers and former smokers (NLST). In the cohort, lung cancer occurred at 2.3 per 1,000 person-years overall and 7.1 per 1,000 person-years among smokers with high asbestos exposure. For the whole cohort, yearly screening was estimated at about 170,000 euros per quality-adjusted life year (QALY) gained (95% confidence interval 74,000 to 645,000). For a hypothetical group of smokers with high exposure, the estimates were about 90,000 euros per QALY with yearly scans (35,000 to 276,000) and 45,000 euros per QALY with scans every two years (15,000 to 116,000). The authors concluded that two-yearly scans for smokers with high exposure are acceptable by usual thresholds and preferable to yearly scans. They noted the trial population differed from the asbestos-exposed workers, and only direct costs were counted.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Cost-effectiveness modelling study (Markov model, 1-year cycles, lifetime horizon). It compared monitoring without intervention with annual low-dose CT lung cancer screening, plus sensitivity analyses including screening every 2 years. Screening effects came from the NLST trial, which enrolled smokers and former smokers, and lung cancer rates came from the ARDCO cohort.
• Who was studied: The ARDCO cohort: 14,218 retired or unemployed workers with a history of occupational asbestos exposure in four French regions (94.8% men). They were followed for lung cancer diagnosis and vital status until July 2019. A hypothetical population of 14,218 smokers with high asbestos exposure was also modelled.
• Exposure: Occupational asbestos exposure, graded low, intermediate or high by industrial hygienists from each person's full work history. The distribution was 7.5% low, 67.9% intermediate and 24.5% high (Table 1). No fiber types were specified. Smoking status, pleural plaques and asbestosis were used to define subgroups.
• Main results:
  • Observed lung cancer incidence in the ARDCO cohort was 2.3 per 1000 person-years for the whole cohort and 7.1 per 1000 person-years for smokers with high asbestos exposure.
  • Whole cohort, annual screening (modelled): incremental cost 6900 € [3700–11,800 €] per person and QALY gain 0.040 [0.010–0.065] per person. The ICER was 170,000 [74,000–645,000] €/QALY (Table 4: 171,575 €/QALY, range 74,669–644,761).
  • Smokers with high asbestos exposure, annual screening (modelled): cost 13,000 € [5652–26,800 €] per person and QALY gain 0.144 [0.071–0.216]. The ICER was 90,000 [35,000–276,000] €/QALY.
  • With scans every 2 years, the modelled ICERs were 64,000 [20,000–143,000] €/QALY for the whole cohort and 45,000 [15,000–116,000] €/QALY for smokers with high exposure.
  • In the sensitivity analysis for smokers with high exposure, the interval between scans was the parameter that most improved the ICER.
  • Using the NLST false-positive rate (23.3%) instead of the NELSON-based rate gave an ICER of 65,000 €/QALY, compared with 45,000 €/QALY.
  • At an acceptability threshold of 50,000 €/QALY, biennial screening of smokers with high exposure was cost-effective in 58.5% of the model simulations.
• The authors' conclusion: The authors concluded that, by usual ICER thresholds, low-dose CT screening every 2 years for smokers with high occupational asbestos exposure is acceptable and preferable to annual screening. They added that an ongoing clinical trial is expected to validate the model.
• Limitations the authors state:
  • The NLST population, from which screening efficacy was taken, differed from the asbestos-exposed ARDCO participants in smoking status, occupational exposure and sex.
  • Only direct costs were counted. Indirect costs linked to overdiagnosis, potential radiation-induced cancers and false-positive morbidities were not included.
  • The model was simplified: all patients with localized lung cancer were assumed to have the same probability of death.
  • There were no French health utility (quality-of-life) data for people with lung cancer.

Topics

Medical terms in this study, explained in our Lexicon: Low-Dose CT Screening, Lung Cancer, Asbestos Exposure, confidence interval, Occupational Exposure.

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• Occupational exposure to ultrafine particles and lung cancer in a population exposed to asbestos — C. Rostello, C. Gramond, et al. (2025)
• CT scan screening is associated with increased distress among subjects of the APExS — C. Paris, M. Maurel, et al. (2010)

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