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.
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.


METHODS
Simulation of life histories using Markov health states.


METHODS
Childhood Cancer Survivor Study; published literature.


METHODS
Childhood cancer survivors.


METHODS
Lifetime.


CONCLUSIONS
Societal.


METHODS
Echocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and β-blocker therapies after ALVD diagnosis.


METHODS
Quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure.


RESULTS
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
The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER.


CONCLUSIONS
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).


CONCLUSIONS
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.
F Lennie
FL
Wong
Smita
S
Bhatia
Wendy
W
Landier
Liton
L
Francisco
Wendy
W
Leisenring
Melissa M
MM
Hudson
Gregory T
GT
Armstrong
Ann
A
Mertens
Marilyn
M
Stovall
Leslie L
LL
Robison
Gary H
GH
Lyman
Steven E
SE
Lipshultz
Saro H
SH
Armenian
D000293:Adolescent; D000319:Adrenergic beta-Antagonists / Q000191:economics / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics / Q000627:therapeutic use*; D018943:Anthracyclines / Q000009:adverse effects; D002648:Child; D003362:Cost-Benefit Analysis; D004452:Echocardiography / Q000191:economics*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D008962:Models, Theoretical; D009369:Neoplasms / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D017410:Practice Guidelines as Topic; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity; D017741:Survivors; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000191:economics
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D018943:Anthracyclines