Elsevier

Lung Cancer

Volume 83, Issue 3, March 2014, Pages 347-355
Lung Cancer

Healthcare costs in the Danish randomised controlled lung cancer CT-screening trial: A registry study

https://doi.org/10.1016/j.lungcan.2013.12.005Get rights and content

Abstract

Objectives

Low dose computerised tomography (CT) screening for lung cancer can reduce lung-cancer-specific mortality. The objective of this study was to analyse healthcare costs and healthcare utilisation of participants in the Danish lung cancer CT-screening trial (DLCST).

Materials and methods

This registry study was nested in a randomised controlled trial (DLCST). 4104 participants, current or former heavy smokers, aged 50–70 years were randomised to five annual low dose CT scans or usual care during 2004–2010. Total healthcare costs and healthcare utilisation data for both the primary and the secondary healthcare sector were retrieved from public registries from randomisation – September 2011 and compared between (1) the CT-screening group and the control group and, (2) the control group and each of the true-positive, false-positive and true-negative groups.

Results

The median annual costs per participant were significantly higher in the CT-screening group (Euros [EUR] 1342, interquartile range [IQR] 750–2980) compared with the control group (EUR 1190, IQR 590–2692) (p < 0.0001). When the cost of the CT-screening programme was excluded, there was no longer a statistically significant difference between the CT-screening group (EUR 1155, IQR 567–2798) and the control group (p = 0.52). Analyses according to the diagnostic groups showed that annual costs were 10.57 (95% CI 7.09–15.75) times higher for the true-positive and 1.67 (95% CI 1.20–2.32) times higher for the false-positive group compared with the control group.

Conclusion

Low dose lung cancer CT screening increases healthcare costs compared with no screening; this difference was attributable to the costs of the CT-screening programme. Overall healthcare costs were higher for the true-positive and false-positive groups than for the control group, also when excluding the cost of the CT-screening programme. This increase was outweighed by the larger true-negative group showing no significant differences in costs compared with the control group.

Introduction

Lung cancer is the primary cause of cancer-related deaths in the world [1], [2]. The National Lung Screening Trial (NLST) has shown a relative risk reduction in lung-cancer-specific mortality of 20% and 6.7% in all-cause mortality using low dose computerised tomography (CT) screening [3]. The Danish Lung Cancer Screening Trial (DLCST) and five other European randomised controlled lung cancer CT-screening trials are currently being evaluated [4], [5], [6], [7], [8], [9], [10]. Data pooling of the European trials is required to show whether the lung-cancer-specific mortality reduction found in NLST is also a consistent result in the European trials. The final data analyses on mortality and overdiagnosis in the European trials are planned in 2015 and therefore cost-effectiveness analyses cannot be performed at present [5]. A recently published Cochrane review concluded that even though a lung-cancer-specific mortality reduction was found in the NLST more data are needed on cost effectiveness, overdiagnosis and false-positive results before recommendations of lung cancer CT-screening programmes should be made [11].

It is currently unclear whether lung cancer CT screening is cost effective [12]. The false positive results will contribute to the total costs of CT screening and the false-positive rate differs across the CT-screening trials (the NLST = 23%, the Dutch-Belgian Lung Cancer Screening Trial (NELSON) = 13% and the DLCST = 3%) [3], [9], [13]. A study analysing the healthcare costs in the NLST found that: “The high false-positive rate of LDCT screening, as reported in the NLST, will clearly contribute to these expenditures, because a false-positive screening result leads to unnecessary follow-up tests and procedures, and their respective costs” [12]. However, the study included only the lung-related costs of the CT screening and follow-up procedures [12]. In mammography screening, it has been shown that both breast-related and non-breast-related outpatient visits increased significantly for those women receiving a false-positive result [14]. Moreover, the diagnostic follow-up of false-positive screening mammography results leads to more concern and more healthcare utilisation in general [14], [15], [16], [17]. Thus, it is important to know whether participants in lung cancer CT screening seek more medical attention not only related to lung cancer screening.

Consequently, the aim of this study was to analyse all healthcare costs in the DLCST population, in both the primary and the secondary healthcare sector, during the screening period. The costs were compared between (1) the screening group and the control group and, (2) the control group and each of the true-positive, false-positive and true-negative groups.

Section snippets

Study population

The DLCST ran during 2004–2010; the study design is described in detail elsewhere [9], [18]. Briefly, 4104 current and former heavy smokers, aged 50–70 years, were randomised to CT screening or no screening with 2052 participants in each group (Fig. 1). The participants in the screening group were offered five annual low dose CT scans. Both groups made annual visits to a screening clinic and received lung function tests, smoking counselling, and completed questionnaires [18], [19].

DLCST budget

The DLCST

Participation

Overall participation in the DLCST was 95.5% in the screening group and 93.0% in the control group (Fig. 1). No significant differences in baseline socioeconomic characteristics or smoking habits were found between the two groups (Table 1). During the screening trial, 148 (3.6%) participants died and 27 (0.6%) emigrated; 31 participants had a total observation time <12 months and were excluded. The data on all 4104 participants in the DLCST were retrieved from the registries and none was lost

Discussion

This is the first study to present the total healthcare costs, in both the primary and secondary healthcare sector, of the participants in a randomised lung cancer CT-screening trial. The total costs of the screening group were significantly higher than the costs of the control group when the costs of the CT-screening programme were included. However, when the costs of the CT-screening programme were excluded, this difference disappeared. Therefore, the excess costs in the screening group were

Conclusion

In this study low dose lung cancer CT screening increases national healthcare costs compared with no screening; this increase is attributable to the costs of the CT-screening programme. Overall healthcare costs were higher for the true-positive and false-positive groups than for the control group, also when excluding the cost of the CT-screening programme. This increase was outweighed by the large true-negative group showing no significant differences in costs compared with the control group.

Conflicts of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; JHP has received a grant funding the DLCST during 2004–2010 from the Danish Ministry of Health and Prevention and JFR received funding from this grant during the work with this present project; JHP participated in a single meeting in an advisory board for Roche Diagnostics on global issues of lung cancer screening; no other

Contributors

The study was devised by JFR, JHP and JB. BH, VS and ZS provided comments. Data collection and data analysis was done by JFR, VS, JHP, ZS and JB. JFR drafted the manuscript and JHP, JB, VS, BH and ZS contributed to revisions of the manuscript and approved the final version to be published. All authors, external and internal, had full access to all of the data (including statistical reports and Tables) in the study and can take responsibility for the integrity of the data and the accuracy of the

Funding

The Danish Lung Cancer Screening Trial and JFR were funded by the Danish Ministry of Health and Prevention (grant number 0900814). The funder had no role in study design, data collection, analysis, interpretation, writing process or in the decision to submit the article for publication.

Acknowledgements

We thank data manager Willy Karlslund for the comprehensive technical work generating the databases.

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