World J Oncol

World Journal of Oncology, ISSN 1920-4531 print, 1920-454X online, Open Access

Article copyright, the authors; Journal compilation copyright, World J Oncol and Elmer Press Inc

Journal website https://www.wjon.org

Original Article

Volume 15, Number 4, August 2024, pages 550-561

Cost-Effectiveness of Low-Dose Computed Tomography Screenings for Lung Cancer in High-Risk Populations: A Markov Model

Figure 1. The Markov model of cost-effectiveness analysis of low-dose computed tomography (LDCT) and chest X-ray (CXR) screenings for lung cancer in high-risk populations.

Figure 2. The Markov decision tree model of cost-effectiveness analysis of low-dose computed tomography (LDCT) and chest X-ray (CXR) screenings for lung cancer in high-risk populations.

Figure 3. Net money benefit (NMB) of low-dose computed tomography (LDCT) and chest X-ray (CXR) screenings for lung cancer in high-risk populations.

Figure 4. Incremental cost-effectiveness scatter plot of low-dose computed tomography (LDCT) and chest X-ray (CXR) screenings for lung cancer in high-risk populations.

Figure 5. Cost-effectiveness acceptability curve of low-dose computed tomography (LDCT) and chest X-ray (CXR) screenings for lung cancer in high-risk populations.

Figure 6. Tornado diagram showing one-way sensitivity analysis results. Bars indicate the effect of a ±10% variance of a variable on the incremental cost-effectiveness ratio (ICER). Costs are expressed in 2022 US$.

**Table 1.** Outcome and Survival Probability, Treat Cost, and Health-State Utilities
Variables	Values	Distribution	Reference
CXR: chest X-ray; HPA: Health Promotion Administration; LDCT: low-dose computed tomography; QALYs: quality-adjusted life years.
Probability
LDCT false positive	96.4%	β	Aberle et al [13]
LDCT cancer detection rate	24.2%	β	Aberle et al [13]
CXR false positive	94.5%	β	Aberle et al [13]
CXR cancer detection rate	6.9%	β	Aberle et al [13]
Lung cancer survival rate stage 0-I	90%	β	HPA [10]
Lung cancer survival rate stage II	60%	β	HPA [10]
Lung cancer survival rate stage III	30%	β	HPA [10]
Lung cancer survival rate stage IV	10%	β	HPA [10]
LDCT lung cancer detection rate stage 0-I	40%	β	Wood et al [15]
LDCT lung cancer detection rate stage II	26%	β	Wood et al [15]
LDCT lung cancer detection rate stage III	12%	β	Wood et al [15]
LDCT lung cancer detection rate stage IV	22%	β	Wood et al [15]
CXR lung cancer detection rate stage 0	0-4.2%	β	Snowsill et al [16], HPA [10]
CXR lung cancer detection rate stage I	18.0-29.1%	β	Snowsill et al [16], HPA [10]
CXR lung cancer detection rate stage II	4.3-8%	β	Snowsill et al [16], HPA [10]
CXR lung cancer detection rate stage III	12.3-21%	β	Snowsill et al [16], HPA [10]
CXR lung cancer detection rate stage IV	50.1-53%	β	Snowsill et al [16], HPA [10]
Cost ($), per cycle: 2 years
LDCT screening examination	200	γ	HPA [10]
Treatment for lung cancer stage I	38,527 (36,546 - 40,968)	γ	Yang et al [17]
Treatment for lung cancer stage II	48,262 (44,656 - 53,412)	γ	Yang et al [17]
Treatment for lung cancer stage III	38,201 (31,111 - 45,191)	γ	Yang et al [17]
Treatment for lung cancer stage IV	26,581 (26,054 - 27,131)	γ	Yang et al [17]
Utility (QALYs)
Lung cancer stage I	0.76	β	Yang et al [17]
Lung cancer stage II	0.37	β	Yang et al [17]
Lung cancer stage III	0.24	β	Yang et al [17]
Lung cancer stage IV	0.09	β	Yang et al [17]
Healthy adults	1		Assumption
Death	0		Assumption

Table 1. Outcome and Survival Probability, Treat Cost, and Health-State Utilities

Variables

Values

Distribution

Reference

CXR: chest X-ray; HPA: Health Promotion Administration; LDCT: low-dose computed tomography; QALYs: quality-adjusted life years.

Probability

LDCT false positive

96.4%

Aberle et al [13]

LDCT cancer detection rate

24.2%

Aberle et al [13]

CXR false positive

94.5%

Aberle et al [13]

CXR cancer detection rate

6.9%

Aberle et al [13]

Lung cancer survival rate stage 0-I

90%

HPA [10]

Lung cancer survival rate stage II

60%

HPA [10]

Lung cancer survival rate stage III

30%

HPA [10]

Lung cancer survival rate stage IV

10%

HPA [10]

LDCT lung cancer detection rate stage 0-I

40%

Wood et al [15]

LDCT lung cancer detection rate stage II

26%

Wood et al [15]

LDCT lung cancer detection rate stage III

12%

Wood et al [15]

LDCT lung cancer detection rate stage IV

22%

Wood et al [15]

CXR lung cancer detection rate stage 0

0-4.2%

Snowsill et al [16], HPA [10]

CXR lung cancer detection rate stage I

18.0-29.1%

Snowsill et al [16], HPA [10]

CXR lung cancer detection rate stage II

4.3-8%

Snowsill et al [16], HPA [10]

CXR lung cancer detection rate stage III

12.3-21%

Snowsill et al [16], HPA [10]

CXR lung cancer detection rate stage IV

50.1-53%

Snowsill et al [16], HPA [10]

Cost ($), per cycle: 2 years

LDCT screening examination

200

HPA [10]

Treatment for lung cancer stage I

38,527 (36,546 - 40,968)

Yang et al [17]

Treatment for lung cancer stage II

48,262 (44,656 - 53,412)

Yang et al [17]

Treatment for lung cancer stage III

38,201 (31,111 - 45,191)

Yang et al [17]

Treatment for lung cancer stage IV

26,581 (26,054 - 27,131)

Yang et al [17]

Utility (QALYs)

Lung cancer stage I

0.76

Yang et al [17]

Lung cancer stage II

0.37

Yang et al [17]

Lung cancer stage III

0.24

Yang et al [17]

Lung cancer stage IV

0.09

Yang et al [17]

Healthy adults

Assumption

Death

Assumption

**Table 2.** Cost-Utility Analysis Between LDCT and CXR Screenings for Lung Cancer in High-Risk Populations
Strategy	Cost ($)	Incremental costs ($)	Effectiveness (QALYs)	Incremental effectiveness (QALYs)	ICUR ($/QALYs)
CXR: chest X-ray; QALYs: quality-adjusted life years; ICUR: incremental cost-utility ratio; LDCT: low-dose computed tomography.
LDCT	84,111	-35,436	3.57	1.43	-24,757.65
CXR	119,567		2.13

Table 2. Cost-Utility Analysis Between LDCT and CXR Screenings for Lung Cancer in High-Risk Populations

Strategy

Cost ($)

Incremental costs ($)

Effectiveness (QALYs)

Incremental effectiveness (QALYs)

ICUR ($/QALYs)

CXR: chest X-ray; QALYs: quality-adjusted life years; ICUR: incremental cost-utility ratio; LDCT: low-dose computed tomography.

LDCT

84,111

-35,436

3.57

1.43

-24,757.65

CXR

119,567

2.13

**Table 3.** The Distribution of Age Group in High-Risk Populations With Smoking in Taiwan
Age group	Population	Smoking rate	Population with smoking
Source: 2020 Taiwan Population Census and Smoking Prevalence Survey [3].
40 - 44	2,016,609	19.80%	399,289
45 - 49	1,760,217	21.80%	383,727
50 - 54	1,806,643	17.90%	323,389
55 - 59	1,824,832	11.20%	204,381
60 - 64	1,677,085	9.20%	154,292
65 - 69	1,445,839	7.40%	106,992
70 - 74	902,349	7.40%	66,774
75 - 79	588,493	7.40%	43,548
80 - 84	445,423	7.40%	32,961
85 - 89	255,428	7.40%	18,902
90 - 94	117,104	7.40%	8,666
95 - 99	28,437	7.40%	2,104
100+	4,242	7.40%	314
≥ 40 years	12,872,701	13.56%	1,745,339

Table 3. The Distribution of Age Group in High-Risk Populations With Smoking in Taiwan

Age group

Population

Smoking rate

Population with smoking

Source: 2020 Taiwan Population Census and Smoking Prevalence Survey [3].

40 - 44

2,016,609

19.80%

399,289

45 - 49

1,760,217

21.80%

383,727

50 - 54

1,806,643

17.90%

323,389

55 - 59

1,824,832

11.20%

204,381

60 - 64

1,677,085

9.20%

154,292

65 - 69

1,445,839

7.40%

106,992

70 - 74

902,349

7.40%

66,774

75 - 79

588,493

7.40%

43,548

80 - 84

445,423

7.40%

32,961

85 - 89

255,428

7.40%

18,902

90 - 94

117,104

7.40%

8,666

95 - 99

28,437

7.40%

2,104

100+

4,242

7.40%

314

≥ 40 years

12,872,701

13.56%

1,745,339

**Table 4.** Summary Findings of Selected Studies of CEA of LDCT and CXR Screenings for Lung Cancer in High-Risk Populations
Authors (years)	Country/study design	Study subjects	Perspectives	Willingness to pay	Major findings
CXR: chest X-ray; HALYs: health-adjusted life years; ICER: incremental cost-effectiveness ratio; LDCT: low-dose computed tomography; NELSON: Nederlands-Leuvens Longkanker Screenings Onderzoek; QALE: quality-adjusted life expectancy; QALYs: quality-adjusted life years.
Present study	Taiwan, Republic of China	55 - 74 years (a high-risk population)	Health provider	$35,514	1. ICER of early lung cancer screening compared LDCT to CXR is US$-24,757.65/QALYs. 2. ICER is highly correlated with the recall rate and treatment costs, while the correlation with biopsy rate and examination costs is lower. 3. The probability of LDCT compared to CXR being more cost-saving is 100%.
Manser et al (2005) [26]	Australia	55 - 75 years (≥ 30 packs/year smokers)	Government payer	$50,000	1. For male smokers aged 60 - 64 years, the ICER was $57,325/LYs and $105,090/QALYs. 2. For females aged 60 - 64 years, the ICER was $51,00/LYs and $88,583/QALYs.
Yang et al (2017) [17]	Taiwan, Republic of China	55 - 75 years (≥ 30 packs/year smokers)	Government payer	$22,755	1. After dividing this by savings of loss-of-QALE (1.16 QALYs), the ICER was US$19,683/QALYs. 2. This ratio would fall to US$10,947/QALYs if the stage distribution for CT screening was the same as that of screen-detected cancers in the NELSON trial.
Tomonaga et al (2018) [27]	Switzerland	A cohort born between 1935 and 1965	Government Payer	€50,000	1. The cost-effectiveness of LDCT screening for lung cancer to be better than €50,000 per LYG (or €70,000 per QALY) for all assessed screening scenarios. 2. These scenarios reduced lung cancer mortality by 6-15% while increasing incidence of lung cancer diagnoses by 2-6%.
McLeod et al (2020) [28]	New Zealand	55 - 74 years (≥ 30 packs/year smokers and those who have quitting within the last 15 years	Government Payer	NZ$45,000	LDCT screening compared to usual care in New Zealand is likely to be cost-effective for the total population: NZ$34,400/HALYs.

Table 4. Summary Findings of Selected Studies of CEA of LDCT and CXR Screenings for Lung Cancer in High-Risk Populations

Authors (years)

Country/study design

Study subjects

Perspectives

Willingness to pay

Major findings

CXR: chest X-ray; HALYs: health-adjusted life years; ICER: incremental cost-effectiveness ratio; LDCT: low-dose computed tomography; NELSON: Nederlands-Leuvens Longkanker Screenings Onderzoek; QALE: quality-adjusted life expectancy; QALYs: quality-adjusted life years.

Present study

Taiwan, Republic of China

55 - 74 years (a high-risk population)

Health provider

$35,514

1. ICER of early lung cancer screening compared LDCT to CXR is US$-24,757.65/QALYs.
2. ICER is highly correlated with the recall rate and treatment costs, while the correlation with biopsy rate and examination costs is lower.
3. The probability of LDCT compared to CXR being more cost-saving is 100%.

Manser et al (2005) [26]

Australia

55 - 75 years (≥ 30 packs/year smokers)

Government payer

$50,000

1. For male smokers aged 60 - 64 years, the ICER was $57,325/LYs and $105,090/QALYs.
2. For females aged 60 - 64 years, the ICER was $51,00/LYs and $88,583/QALYs.

Yang et al (2017) [17]

Taiwan, Republic of China

55 - 75 years (≥ 30 packs/year smokers)

Government payer

$22,755

1. After dividing this by savings of loss-of-QALE (1.16 QALYs), the ICER was US$19,683/QALYs.
2. This ratio would fall to US$10,947/QALYs if the stage distribution for CT screening was the same as that of screen-detected cancers in the NELSON trial.

Tomonaga et al (2018) [27]

Switzerland

A cohort born between 1935 and 1965

Government Payer

€50,000

1. The cost-effectiveness of LDCT screening for lung cancer to be better than €50,000 per LYG (or €70,000 per QALY) for all assessed screening scenarios.
2. These scenarios reduced lung cancer mortality by 6-15% while increasing incidence of lung cancer diagnoses by 2-6%.

McLeod et al (2020) [28]

New Zealand

55 - 74 years (≥ 30 packs/year smokers and those who have quitting within the last 15 years

Government Payer

NZ$45,000

LDCT screening compared to usual care in New Zealand is likely to be cost-effective for the total population: NZ$34,400/HALYs.