title: Low-dose chest computed tomography for lung cancer screening among Hodgkin lymphoma survivors: a cost-effectiveness analysis.
abstract: OBJECTIVE
  Hodgkin lymphoma (HL) survivors face an increased risk of treatment-related lung cancer. Screening with low-dose computed tomography (LDCT) may allow detection of early stage, resectable cancers. We developed a Markov decision-analytic and cost-effectiveness model to estimate the merits of annual LDCT screening among HL survivors.
  
  
  METHODS
  Population databases and HL-specific literature informed key model parameters, including lung cancer rates and stage distribution, cause-specific survival estimates, and utilities. Relative risks accounted for radiation therapy (RT) technique, smoking status (>10 pack-years or current smokers vs not), age at HL diagnosis, time from HL treatment, and excess radiation from LDCTs. LDCT assumptions, including expected stage-shift, false-positive rates, and likely additional workup were derived from the National Lung Screening Trial and preliminary results from an internal phase 2 protocol that performed annual LDCTs in 53 HL survivors. We assumed a 3% discount rate and a willingness-to-pay (WTP) threshold of $50,000 per quality-adjusted life year (QALY).
  
  
  RESULTS
  Annual LDCT screening was cost effective for all smokers. A male smoker treated with mantle RT at age 25 achieved maximum QALYs by initiating screening 12 years post-HL, with a life expectancy benefit of 2.1 months and an incremental cost of $34,841/QALY. Among nonsmokers, annual screening produced a QALY benefit in some cases, but the incremental cost was not below the WTP threshold for any patient subsets. As age at HL diagnosis increased, earlier initiation of screening improved outcomes. Sensitivity analyses revealed that the model was most sensitive to the lung cancer incidence and mortality rates and expected stage-shift from screening.
  
  
  CONCLUSIONS
  HL survivors are an important high-risk population that may benefit from screening, especially those treated in the past with large radiation fields including mantle or involved-field RT. Screening may be cost effective for all smokers but possibly not for nonsmokers despite a small life expectancy benefit.
authors.affiliation: Harvard Radiation Oncology Program, Boston, Massachusetts. Electronic address: dwattson@partners.org.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Wattson
authors.affiliation: Departments of Radiology and Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands and Center for Health Decision Science, Harvard School of Public Health, Boston, Massachusetts.
authors.forename: M G Myriam
authors.initials: MG
authors.lastname: Hunink
authors.affiliation: Department of Imaging, Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Pamela J
authors.initials: PJ
authors.lastname: DiPiro
authors.affiliation: Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Prajnan
authors.initials: P
authors.lastname: Das
authors.affiliation: Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
authors.forename: David C
authors.initials: DC
authors.lastname: Hodgson
authors.affiliation: Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Mauch
authors.affiliation: Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Ng
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer; D005260:Female; D006689:Hodgkin Disease / Q000532:radiotherapy*; D006801:Humans; D008017:Life Expectancy; D008175:Lung Neoplasms / Q000000981:diagnostic imaging*; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D016609:Neoplasms, Second Primary / Q000000981:diagnostic imaging*; D011829:Radiation Dosage; D012306:Risk; D012737:Sex Factors; D012907:Smoking; D017741:Survivors; D014057:Tomography, X-Ray Computed / Q000191:economics* / Q000379:methods