Influence of changing patterns in lung cancer treatment and survival on the cost-effectiveness of CT screening: a modeling study.

Background: With the introduction of immune- and targeted therapies, lung cancer survival has lengthened, but per-patient costs of treatment have also increased. Both the clinical outcomes and costs of late stage disease have bearing on the benefits and relative cost of early detection interventions. Cost-effectiveness estimates of lung cancer (LC) computed tomography (CT) screening, crucial for policymaking, using such real-world recent data have been limited. Methods: Registry data of the entire Dutch LC patient population (n = 137,129) inform treatment cost and real-world survival before (2012-2017) and after (2018-2021) widespread novel therapy introduction. The MISCAN-Lung (MIcrosimulation SCreening Analysis) microsimulation model projects the population-level benefits and harms of CT screening for Dutch 1949-1979 cohorts. Findings: From 2012-2017 to 2018-2021, per-patient care expenditures increased 52%. Survival improvements differ by patient subgroup; for males <65 y, 3-year relative survival for stage-IV adenocarcinoma increased from 10.6% to 22%. MISCAN model simulations found annual screening ages 55-75 from 1.51% PLCOm-risk (Prostatem Lung Colorectal Ovarian Screening trial model) as cost-effective (<€20,000 per Quality Adjusted Life Years Gained (QALYG)). After adjusting LC survival to novel therapies, screening is expected to yield 3253 QALYG and 4118 LYG per 100,000 population, 3.2% (QALYG) and 3.7% (LYG) lower than before novel therapies. However, expected net screening costs decrease 16.7% as late-stage treatment has become more expensive and is applied longer; the savings in late-stage therapy cost were estimated to have increased 183%. The cost per QALYG decreased 13.9%, from €14,172/QALY to €12,201/QALY. Interpretation: Novel treatments for late-stage lung cancer have made lung cancer screening more cost-effective. While LC survival improves due to novel treatments for advanced disease, the increased expenditures outpace survival gains. Screening implementation still needs prioritization, even as late-stage LC survival improves. Funding: European Union Horizon 2020 grant 848294: 4-IN-THE-LUNG-RUN. VENI grant number 09150161910060 (Dutch Research Council/Netherlands Organisation of Health Research (ZonMW)).