Risk Model-Based Lung Cancer Screening : A Cost-Effectiveness Analysis

Ann Intern Med. 2023 Mar;176(3):320-332. doi: 10.7326/M22-2216. Epub 2023 Feb 7.


Background: In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model-based strategies), highlighting the need for further research on the benefits and harms of risk model-based screening.

Objective: To evaluate and compare the cost-effectiveness of risk model-based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds.

Design: Comparative modeling analysis.

Data sources: National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator.

Target population: 1960 U.S. birth cohort.

Time horizon: 45 years.

Perspective: U.S. health care sector.

Intervention: Annual low-dose computed tomography in risk model-based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model.

Outcome measures: Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost.

Results of base-case analysis: Risk model-based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2% risk threshold had an ICER of $94 659 (model range, $72 639 to $156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%).

Results of sensitivity analyses: Risk model-based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions.

Limitation: Risk models were restricted to age, sex, and smoking-related risk predictors.

Conclusion: Risk model-based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration.

Primary funding source: National Cancer Institute (NCI).

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged, 80 and over
  • Cost-Benefit Analysis
  • Cost-Effectiveness Analysis
  • Early Detection of Cancer / methods
  • Humans
  • Lung
  • Lung Neoplasms* / diagnostic imaging
  • Mass Screening / methods
  • Middle Aged
  • Quality-Adjusted Life Years