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

Ann Intern Med. 2014 May 20;160(10):672-83. doi: 10.7326/M13-2498.


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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adrenergic beta-Antagonists / economics
  • Adrenergic beta-Antagonists / therapeutic use*
  • Adult
  • Aged
  • Angiotensin-Converting Enzyme Inhibitors / economics
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Anthracyclines / adverse effects
  • Child
  • Cost-Benefit Analysis
  • Echocardiography / economics*
  • Female
  • Follow-Up Studies
  • Heart Failure / epidemiology
  • Heart Failure / etiology
  • Heart Failure / prevention & control*
  • Humans
  • Incidence
  • Male
  • Markov Chains
  • Middle Aged
  • Models, Theoretical
  • Neoplasms / complications*
  • Neoplasms / drug therapy
  • Neoplasms / mortality
  • Practice Guidelines as Topic*
  • Quality-Adjusted Life Years
  • Sensitivity and Specificity
  • Survivors
  • Ventricular Dysfunction, Left / diagnostic imaging*
  • Ventricular Dysfunction, Left / drug therapy
  • Ventricular Dysfunction, Left / economics


  • Adrenergic beta-Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Anthracyclines