Cost-Effectiveness Analysis of Lung Cancer Screening in the United States: A Comparative Modeling Study

Ann Intern Med. 2019 Dec 3;171(11):796-804. doi: 10.7326/M19-0322. Epub 2019 Nov 5.


Background: Recommendations vary regarding the maximum age at which to stop lung cancer screening: 80 years according to the U.S. Preventive Services Task Force (USPSTF), 77 years according to the Centers for Medicare & Medicaid Services (CMS), and 74 years according to the National Lung Screening Trial (NLST).

Objective: To compare the cost-effectiveness of different stopping ages for lung cancer screening.

Design: By using shared inputs for smoking behavior, costs, and quality of life, 4 independently developed microsimulation models evaluated the health and cost outcomes of annual lung cancer screening with low-dose computed tomography (LDCT).

Data sources: The NLST; Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial; SEER (Surveillance, Epidemiology, and End Results) program; Nurses' Health Study and Health Professionals Follow-up Study; and U.S. Smoking History Generator.

Target population: Current, former, and never-smokers aged 45 years from the 1960 U.S. birth cohort.

Time horizon: 45 years.

Perspective: Health care sector.

Intervention: Annual LDCT according to NLST, CMS, and USPSTF criteria.

Outcome measures: Incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY).

Results of base-case analysis: The 4 models showed that the NLST, CMS, and USPSTF screening strategies were cost-effective, with ICERs averaging $49 200, $68 600, and $96 700 per QALY, respectively. Increasing the age at which to stop screening resulted in a greater reduction in mortality but also led to higher costs and overdiagnosis rates.

Results of sensitivity analysis: Probabilistic sensitivity analysis showed that the NLST and CMS strategies had higher probabilities of being cost-effective (98% and 77%, respectively) than the USPSTF strategy (52%).

Limitation: Scenarios assumed 100% screening adherence, and models extrapolated beyond clinical trial data.

Conclusion: All 3 sets of lung cancer screening criteria represent cost-effective programs. Despite underlying uncertainty, the NLST and CMS screening strategies have high probabilities of being cost-effective.

Primary funding source: CISNET (Cancer Intervention and Surveillance Modeling Network) Lung Group, National Cancer Institute.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cost-Benefit Analysis*
  • Early Detection of Cancer / economics*
  • Early Detection of Cancer / methods
  • Humans
  • Lung Neoplasms / diagnosis*
  • Lung Neoplasms / epidemiology
  • Mass Screening / economics*
  • Mass Screening / methods
  • Middle Aged
  • Models, Statistical*
  • Quality of Life
  • Risk Factors
  • Sensitivity and Specificity
  • Smoking / adverse effects
  • Tomography, X-Ray Computed / economics
  • United States / epidemiology