Cost-effectiveness of the children's oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure

Abstract

Background: Childhood cancer survivors treated with anthracyclines are at high risk for asymptomatic left ventricular dysfunction (ALVD), subsequent heart failure, and death. The consensus-based Children's Oncology Group (COG) Long-Term Follow-up Guidelines recommend lifetime echocardiographic screening for ALVD.

Objective: To evaluate the efficacy and cost-effectiveness of the COG guidelines and to identify more cost-effective screening strategies.

Design: Simulation of life histories using Markov health states.

Data sources: Childhood Cancer Survivor Study; published literature.

Target population: Childhood cancer survivors.

Time horizon: Lifetime.

Perspective: Societal.

Intervention: Echocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and β-blocker therapies after ALVD diagnosis.

Outcome measures: Quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure.

Results of base-case analysis: The COG guidelines versus no screening have an ICER of $61 500, extend life expectancy by 6 months and QALYs by 1.6 months, and reduce the cumulative incidence of heart failure by 18% at 30 years after cancer diagnosis. However, less frequent screenings are more cost-effective than the guidelines and maintain 80% of the health benefits.

Results of sensitivity analysis: The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER.

Limitation: Lifetime non-heart failure mortality and the cumulative incidence of heart failure more than 20 years after diagnosis were extrapolated; the efficacy of ACE inhibitor and β-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown).

Conclusion: The COG guidelines could reduce the risk for heart failure in survivors at less than $100 000/QALY. Less frequent screening achieves most of the benefits and would be more cost-effective than the COG guidelines.

Appendix Figure 1

Four-health state transition diagram. ALVD = asymptomatic left ventricular dysfunction HF = heart failure

Appendix Figure 2

Annual incidence of HF by years since cancer diagnosis, for A) age at cancer diagnosis < 5 years; B) age at cancer diagnosis ≥ 5 years HF = heart failure

Appendix Figure 2

Annual incidence of HF by years since cancer diagnosis, for A) age at cancer diagnosis < 5 years; B) age at cancer diagnosis ≥ 5 years HF = heart failure

Appendix Figure 3

Annual non-HF mortality by attained age HF = heart failure RR = relative risk (compared to the U.S. population)

Appendix Figure 4

Two-way sensitivity analyses for ICER, by varying the efficacy of ALVD treatment and the sensitivity and specificity of echocardiography for detecting ALVD ALVD = asymptomatic left ventricular dysfunction ICER = incremental cost-effectiveness ratio QALY = quality-adjusted life-year

Figure 1

Tornado diagrams of the one-way sensitivity analyses for ICER and the percent reduction in the cumulative incidence of HF at 30 years after cancer diagnosis, by varying key variables. ACE = angiotensin-converting enzyme HF = heart failure ICER = incremental cost-effectiveness ratio QALY = quality-adjusted life-year