E-Cigarette Use and Lung Cancer Screening Uptake.

This cross-sectional study examines e-cigarette use and lung cancer screening uptake among individuals in the US.

Trends in uterine cancer incidence in the United States: The contribution of age, period and cohort effects.

OBJECTIVE: In the U.S., uterine cancer incidence is rising, with racial and ethnic minorities experiencing the largest increases. We performed age-period-cohort analyses using novel methods to examine the contribution of age at diagnosis (age), year of diagnosis (period), and birth cohort (cohort), to trends in uterine cancer incidence. METHODS: We used uterine cancer incidence data from the Surveillance, Epidemiology, and End Result (SEER) 12 database (1992-2019), and performed hysterectomy-correction. We generated hexamaps to visualize age, period, and cohort effects, and used mutual information to estimate the percent contribution of age, period, and cohort effects, individually and combined, on uterine cancer incidence, overall and by race and ethnicity and histology. RESULTS: Hexamaps showed an increase in uterine cancer in later time periods, and a cohort effect around 1933 showing a lower incidence compared with earlier and later cohorts. Age, period, and cohort effects combined contributed 86.6% (95% CI: 86.4%, 86.9%) to the incidence. Age effects had the greatest contribution (65.1%, 95% CI: 64.3%, 65.9), followed by cohort (20.7%, 95% CI: 20.1%, 21.3%) and period (14.2%, 95% CI: 13.7%, 14.8%) effects. Hexamaps showed higher incidence in recent years for non-Hispanic Blacks and non-endometrioid tumors. CONCLUSIONS: Age effects had the largest contribution to uterine cancer incidence, followed by cohort and period effects overall and across racial and ethnic groups and histologies. IMPACT: These findings can inform uterine cancer modeling studies on the effects of interventions that target risk factors which may vary across age, period, or cohort.

The Benefits and Harms of Lung Cancer Screening in Individuals With Comorbidities.

Introduction: Individuals with a history of smoking and a high risk of lung cancer often have a high prevalence of smoking-related comorbidities. The presence of these comorbidities might alter the benefit-to-harm ratio of lung cancer screening by influencing the risk of complications, quality of life, and competing risks of death. Nevertheless, individuals with chronic diseases are underrepresented in screening clinical trials. In this study, we use microsimulation modeling to determine the impact of chronic diseases on lung cancer benefits and harms. Methods: We extended a validated lung cancer screening microsimulation model that comprehensively recapitulates an individual's lung cancer development, progression, detection, follow-up, treatment, and survival. We parameterized the model to reflect the impact of chronic diseases on complications from invasive testing, quality of life, and mortality in individuals in five-year age categories between the ages of 50 and 80 years. Outcomes included life-years (LY) gained per 100,000 in patients with chronic obstructive pulmonary disease, diabetes mellitus, heart disease, and history of stroke compared with screening-eligible individuals without comorbidities. Results: Among individuals between the ages of 50 and 54 years, we found that the presence of a comorbidity altered the LY gained from screening per 100,000 individuals depending on the comorbidity: 4296 LY with no comorbidities; 3462 LY, 3260 LY, 3031 LY, and 3257 LY with chronic obstructive pulmonary disease, heart disease, diabetes mellitus, and stroke, respectively. We observed greater reductions in LY gained in individuals with two comorbidities; we observed similar patterns for individuals between the ages of 55 and 59 years, 60 and 64 years, 65 and 69 years, 70 and 74 years, and 75 and 80 years. Conclusions: Comorbidities reduce LY gained from screening per 100,000 compared with no comorbidities, and our results can be used by clinicians when discussing the benefits and harms of screening in their patients with comorbidities.

Comparison of Stage I Non-Small-Cell Lung Cancer Treatments for Patients Living With HIV: A Simulation Study.

INTRODUCTION: Non-small-cell lung cancer (NSCLC) is a leading cause of death for people living with HIV (PWH). Nevertheless, there are no clinical trial data regarding the management of early-stage lung cancer in PWH. Using data from large HIV and cancer cohorts we parameterized a simulation model to compare treatments for stage I NSCLC according to patient characteristics. MATERIALS AND METHODS: To parameterize the model we analyzed PWH and NSCLC patient outcomes and quality of life data from several large cohort studies. Comparative effectiveness of 4 stage I NSCLC treatments (lobectomy, segmentectomy, wedge resection, and stereotactic body radiotherapy) was estimated using evidence synthesis methods. We then simulated trials comparing treatments according to quality adjusted life year (QALY) gains by age, tumor size and histology, HIV disease characteristics and major comorbidities. RESULTS: Lobectomy and segmentectomy yielded the greatest QALY gains among all simulated age, tumor size and comorbidity groups. Optimal treatment strategies differed by patient sex, age, and HIV disease status; wedge resection was among the optimal strategies for women aged 80 to 84 years with tumors 0 to 2 cm in size. Stereotactic body radiotherapy was included in some optimal strategies for patients aged 80 to 84 years with multimorbidity and in sensitivity analyses was a non-inferior option for many older patients or those with poor HIV disease control. CONCLUSION: In simulated comparative trials of treatments for stage I NSCLC in PWH, extensive surgical resection was often associated with the greatest projected QALY gains although less aggressive strategies were predicted to be non-inferior in some older, comorbid patient groups.

Impact of diabetes on stage I lung cancer treatment patterns and prognosis in older adults: A population-based cohort study.

Background: Diabetes is a common comorbidity in patients with early-stage non-small cell lung cancer (NSCLC), a growing population due to increased LC screening. However, it is unknown if diabetes is associated with less aggressive NSCLC treatment and worse NSCLC outcomes. This study aimed to investigate treatment patterns and outcomes of older patients with Stage I NSCLC and diabetes. Methods: Using national cancer registry data linked to Medicare, we identified patients ≥65 years old with Stage I NSCLC. Patients were categorized as having no diabetes, diabetes without severe complications (DM-c), or diabetes with ≥1 severe complication (DM + c). We used multinomial logistic regression to assess the association of diabetes and NSCLC treatment. The association of diabetes category with NSCLC and non-NSCLC survival was analyzed with Fine-Grey competing-risks regression. Results: In 25,358 patients (75% no diabetes, 12% DM-c and 13% had DM + c), adjusted analyses showed that DM-c and DM + c were associated with increased odds of receiving limited resection rather than lobectomy (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.07-1.37 and OR 1.42, 95% CI 1.26-1.59, respectively). Competing risk regression showed diabetes was associated with increased risk of non-NSCLC death (DM-c hazard ratio [HR] 1.16, 95% CI: 1.08-1.25, DM + c HR 1.49, 95% CI: 1.40-1.59), but not NSCLC-specific death. Conclusion: This study uncovers critical information on how diabetes is associated with less aggressive early-stage NSCLC care in older patients. This study also confirms that diabetes increases death from non-lung cancer causes and managing comorbidities is crucial to improving outcomes in older early-stage NSCLC survivors.

Cost-effectiveness of Follow-up CT for Incidental Ascending Aortic Dilatation.

Purpose: To evaluate the cost-effectiveness of CT follow-up strategies for incidental aortic dilatation. Materials and Methods: In this cost-effectiveness analysis, a simulation model was developed with 1 000 000 adult patients aged 55-75 years with incidentally detected dilated aortas measuring 40-50 mm. Follow-up CT strategies were evaluated for various patient age- and aortic size-based cutoffs. Follow-up frequency ranged from 1 to 3 years, as well as a single follow-up CT examination at 1 year. Patient survival was determined by risk of aortic dissection or rupture and surgical- and age-based mortality. Costs and quality-adjusted life-years (QALYs) were calculated for each strategy within the simulated cohort. A probabilistic sensitivity analysis was performed by varying model parameters. Results: The cost-effective strategy with the highest QALYs under a willingness-to-pay threshold of $100 000 per QALY was follow-up CT for patients younger than 60 years with aortas measuring at least 40 mm in diameter every 3 years (incremental cost-effectiveness ratio, $62 511; 95% CI: $52 168, $77 739). With this strategy, follow-up imaging was needed for only 17% of dilated aortas in the cohort. Probabilistic sensitivity analysis demonstrated that the cost-effective strategies at $100 000 per QALY threshold included the following: no follow-up for patients with aortas smaller than 50 mm (39% of simulations), follow-up every 3 years for patients younger than 55 years with aortas measuring at least 45 mm (21%), and follow-up every 3 years for patients older than 65 years with aortas measuring at least 40 mm (14%). Conclusion: Follow-up CT for an incidentally detected dilated ascending aorta smaller than 50 mm is likely not cost-effective in patients older than 60-65 years.Keywords: CT, Thorax, Vascular, Aorta, Cost-Effectiveness, Cost-Benefit Analysis Supplemental material is available for this article. © RSNA, 2023See also commentary by Shen and Fleischmann in this issue.

Risk Model-Based Lung Cancer Screening : A Cost-Effectiveness Analysis.

BACKGROUND: In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model-based strategies), highlighting the need for further research on the benefits and harms of risk model-based screening. OBJECTIVE: To evaluate and compare the cost-effectiveness of risk model-based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds. DESIGN: Comparative modeling analysis. DATA SOURCES: National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator. TARGET POPULATION: 1960 U.S. birth cohort. TIME HORIZON: 45 years. PERSPECTIVE: U.S. health care sector. INTERVENTION: Annual low-dose computed tomography in risk model-based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model. OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost. RESULTS OF BASE-CASE ANALYSIS: Risk model-based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2% risk threshold had an ICER of $94 659 (model range, $72 639 to $156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%). RESULTS OF SENSITIVITY ANALYSES: Risk model-based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions. LIMITATION: Risk models were restricted to age, sex, and smoking-related risk predictors. CONCLUSION: Risk model-based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration. PRIMARY FUNDING SOURCE: National Cancer Institute (NCI).

SCLC: Epidemiology, Risk Factors, Genetic Susceptibility, Molecular Pathology, Screening, and Early Detection.

We review research regarding the epidemiology, risk factors, genetic susceptibility, molecular pathology, and early detection of SCLC, a deadly tumor that accounts for 14% of lung cancers. We first summarize the changing incidences of SCLC globally and in the United States among males and females. We then review the established risk factor (i.e., tobacco smoking) and suspected nonsmoking-related risk factors for SCLC, and emphasize the importance of continued effort in tobacco control worldwide. Review of genetic susceptibility and molecular pathology suggests different molecular pathways in SCLC development compared with other types of lung cancer. Last, we comment on the limited utility of low-dose computed tomography screening in SCLC and on several promising blood-based molecular biomarkers as potential tools in SCLC early detection.

The benefits and harms of adjuvant chemotherapy for non-small cell lung cancer in patients with major comorbidities: A simulation study.

BACKGROUND: Randomized controlled trials (RCTs) have demonstrated a survival benefit for adjuvant platinum-based chemotherapy after resection of locoregional non-small cell lung cancer (NSCLC). The relative benefits and harms and optimal approach to treatment for NSCLC patients who have major comorbidities (chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], and congestive heart failure [CHF]) are unclear, however. METHODS: We used a simulation model to run in-silico comparative trials of adjuvant chemotherapy versus observation in locoregional NSCLC in patients with comorbidities. The model estimated quality-adjusted life years (QALYs) gained by each treatment strategy stratified by age, comorbidity, and stage. The model was parameterized using outcomes and quality-of-life data from RCTs and primary analyses from large cancer databases. RESULTS: Adjuvant chemotherapy was associated with clinically significant QALY gains for all patient age/stage combinations with COPD except for patients >80 years old with Stage IB and IIA cancers. For patients with CHF and Stage IB and IIA disease, adjuvant chemotherapy was not advantageous; in contrast, it was associated with QALY gains for more advanced stages for younger patients with CHF. For stages IIB and IIIA NSCLC, most patient groups benefited from adjuvant chemotherapy. However, In general, patients with multiple comorbidities benefited less from adjuvant chemotherapy than those with single comorbidities and women with comorbidities in older age categories benefited more from adjuvant chemotherapy than their male counterparts. CONCLUSIONS: Older, multimorbid patients may derive QALY gains from adjuvant chemotherapy after NSCLC surgery. These results help extend existing clinical trial data to specific unstudied, high-risk populations and may reduce the uncertainty regarding adjuvant chemotherapy use in these patients.

Optimizing the use of adjuvant chemotherapy in non-small cell lung cancer patients with comorbidities.

Veterans with locoregional non-small cell lung cancer (NSCLC) may benefit from adjuvant chemotherapy. However, comorbidities and other factors may impact the harms and benefits of this treatment. Here, we identified the optimal indications for adjuvant chemotherapy in Veterans with NSCLC, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and/or coronary artery disease (CAD). We used data from randomized controlled trials (RCTs) and Veterans Administration (VA) databases to enhance a simulation model. Then, we conducted in-silico RCTs comparing adjuvant chemotherapy vs observation among Veterans with stage II-IIIA NSCLC. Among Veterans without COPD or CKD, adjuvant chemotherapy was the optimal strategy regardless of the presence or absence of CAD except for patients >70 years with squamous cell carcinoma. Conversely, most veterans without COPD but with CKD were optimally managed with observation. Veterans with COPD but without CKD, benefited from adjuvant chemotherapy if they were ≤70 years with stage II-IIIA adenocarcinoma or <60 years with stage II-IIIA squamous cell carcinoma. Adjuvant chemotherapy was only beneficial for Veterans with both COPD and CKD among stage II-IIIA adenocarcinoma <60 years of age. Veterans with stages II-IIIA squamous cell carcinoma, COPD, and CKD were optimally managed with observation. Many Veterans with comorbidities are optimally managed with observation post-surgical resection. However, we also identified several groups of Veterans whom the benefits of adjuvant chemotherapy outweighed the risks of early toxicity. Our findings could inform patient-provider discussions and potentially reduce physicians' uncertainty about the role of adjuvant chemotherapy in this population.

Endoscopic Screening Program for Control of Esophageal Adenocarcinoma in Varied Populations: A Comparative Cost-Effectiveness Analysis.

BACKGROUND & AIMS: Guidelines suggest endoscopic screening for esophageal adenocarcinoma (EAC) among individuals with symptoms of gastroesophageal reflux disease (GERD) and additional risk factors. We aimed to determine at what age to perform screening and whether sex and race should influence the decision. METHODS: We conducted comparative cost-effectiveness analyses using 3 independent simulation models. For each combination of sex and race (White/Black, 100,000 individuals each), we considered 41 screening strategies, including one-time or repeated screening. The optimal strategy was that with the highest effectiveness and an incremental cost-effectiveness ratio <$100,000 per quality-adjusted life-year gained. RESULTS: Among White men, 536 EAC deaths were projected without screening, and screening individuals with GERD twice at ages 45 and 60 years was optimal. Screening the entire White male population once at age 55 years was optimal in 26% of probabilistic sensitivity analysis runs. Black men had fewer EAC deaths without screening (n = 84), and screening those with GERD once at age 55 years was optimal. Although White women had slightly more EAC deaths (n = 103) than Black men, the optimal strategy was no screening, although screening those with GERD once at age 55 years was optimal in 29% of probabilistic sensitivity analysis runs. Black women had a very low burden of EAC deaths (n = 29), and no screening was optimal, as benefits were very small and some strategies caused net harm. CONCLUSIONS: The optimal strategy for screening differs by race and sex. White men with GERD symptoms can potentially be screened more intensely than is recommended currently. Screening women is not cost-effective and may cause net harm for Black women.

Lung cancer incidence among world trade center rescue and recovery workers.

BACKGROUND: Many World Trade Center disaster (WTC) rescue and recovery workers (WTC RRWV) were exposed to toxic inhalable particles. The impact of WTC exposures on lung cancer risk is unclear. METHODS: Data from the WTC Health Program General Responders Cohort (WTCGRC) were linked to health information from a large New York City health system to identify incident lung cancer cases. Incidence rates for lung cancer were then calculated. As a comparison group, we created a microsimulation model that generated expected lung cancer incidence rates for a WTC- and occupationally-unexposed cohort with similar characteristics. We also fitted a Poisson regression model to determine specific lung cancer risk factors for WTC RRWV. RESULTS: The incidence of lung cancer for WTC RRWV was 39.5 (95% confidence interval [CI]: 30.7-49.9) per 100,000 person-years. When compared to the simulated unexposed cohort, no significant elevation in incidence was found among WTC RRWV (incidence rate ratio [IRR] 1.34; 95% CI: 0.92-1.96). Predictors of lung cancer incidence included age, smoking intensity, and years since quitting for former smokers. In adjusted models evaluating airway obstruction and individual pre-WTC occupational exposures, only mineral dust work was associated with lung cancer risk (IRR: 2.03; 95% CI: 1.07-3.86). DISCUSSION: In a sample from a large, prospective cohort of WTC RRWV we found a lung cancer incidence rate that was similar to that expected of a WTC- and occupationally-unexposed cohort with similar individual risk profiles. Guideline-concordant lung cancer surveillance and periodic evaluations of population-level lung cancer risk should continue in this group.

Cost-effectiveness of neoadjuvant FOLFIRINOX versus gemcitabine plus nab-paclitaxel in borderline resectable/locally advanced pancreatic cancer patients.

BACKGROUND: The 2020 National Comprehensive Cancer Network guidelines recommend neoadjuvant FOLFIRINOX or neoadjuvant gemcitabine plus nab-paclitaxel (G-nP) for borderline resectable/locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC). AIM: The purpose of our study was to compare treatment outcomes, toxicity profiles, costs, and quality-of-life measures between these two treatments to further inform clinical decision-making. METHODS AND RESULTS: We developed a decision-analytic mathematical model to compare the total cost and health outcomes of neoadjuvant FOLFIRINOX against G-nP over 12 years. The model inputs were estimated using clinical trial data and published literature. The primary endpoint was incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100 000 per quality-adjusted-life-year (QALY). Secondary endpoints included overall (OS) and progression-free survival (PFS), total cost of care, QALYs, PDAC resection rate, and monthly treatment-related adverse events (TRAE) costs (USD). FOLFIRINOX was the cost-effective strategy, with an ICER of $60856.47 per QALY when compared to G-nP. G-nP had an ICER of $44639.71 per QALY when compared to natural history. For clinical outcomes, more patients underwent an "R0" resection with FOLFIRINOX compared to G-nP (84.9 vs. 81.0%), but FOLFIRINOX had higher TRAE costs than G-nP ($10905.19 vs. $4894.11). A one-way sensitivity analysis found that the ICER of FOLFIRINOX exceeded the threshold when TRAE costs were higher or PDAC recurrence rates were lower. CONCLUSION: Our modeling analysis suggests that FOLFIRNOX is the cost-effective treatment compared to G-nP for BR/LA PDAC despite having a higher cost of total care due to TRAE costs. Trial data with sufficient follow-up are needed to confirm our findings.

Risk of Cardiovascular Toxicity According to Tumor Laterality Among Older Patients With Early Stage Non-small Cell Lung Cancer Treated With Radiation Therapy.

BACKGROUND: The long-term risk of cardiovascular outcomes from either stereotactic body radiation therapy (SBRT) or three-dimensional conformal radiation therapy (3DCRT) plus intensity-modulated radiation therapy (IMRT) to treat early stage non-small cell lung cancer (NSCLC) is largely unknown. As continued adoption of SBRT accelerates, it is important to delineate unforeseen cardiovascular risks associated with treatment. RESEARCH QUESTION: Does the long-term risk of cardiovascular outcomes for patients with early stage NSCLC treated with either SBRT or 3DCRT plus IMRT differ by tumor laterality? STUDY DESIGN AND METHODS: Data from the Surveillance, Epidemiology, and End Results registry linked to Medicare was analyzed to identify a sample of 3,256 patients (1,506 treated with SBRT and 1,750 treated with 3DCRT plus IMRT) with node-negative stage I or IIA NSCLC. Cardiovascular events were identified using diagnosis codes, and outcomes were compared between left- and right-sided tumors. We assumed that tumor laterality was random and that the radiation field for left-sided tumors likely would result in greater dose to cardiac tissues. Cox regression models were fit to quantify the association of laterality on outcomes. RESULTS: Patients were followed up for a median of 2 years. Those treated with SBRT showed no difference in hazard of any cardiovascular outcomes by tumor laterality, including the cardiovascular composite (hazard ratio [HR] comparing left- vs right-sided tumors, 0.98; 95% CI, 0.84-1.15). In contrast, patients treated with 3DCRT plus IMRT showed a greater risk of congestive heart failure (HR, 1.23; 95% CI, 1.01-1.48) and percutaneous coronary artery intervention (HR, 2.24; 95% CI, 1.12-4.47). INTERPRETATION: Patients with left- vs right-sided early stage NSCLC showed similar rates of cardiovascular events when treated with SBRT. However, these patients also showed higher rates of select cardiac events when they were treated with 3DCRT plus IMRT. This study provides evidence that SBRT may provide a safer option over 3DCRT plus IMRT for patients with left-sided early stage NSCLC and underscores the need for long-term follow-up for patients treated with radiation therapy.

Factors Influencing the False Positive Rate in CT Lung Cancer Screening.

PURPOSE: To identify factors influencing the likelihood of a false positive lung cancer screening (LCS) computed tomography (CT), which may lead to increased costs and patient anxiety. MATERIALS AND METHODS: In this retrospective study, we examined all LCS CTs performed across our healthcare network from 2014 to 2018, recording Lung-RADS category and diagnosis of lung cancer. A false positive was defined by Lung-RADS 3-4X and no diagnosis of lung cancer within 1 year. Patient demographics and smoking history, presence of emphysema, diagnosis of chronic obstructive pulmonary disease, radiologist years of experience and annual volume, income level by patient zip code, and screening institution were evaluated in a multivariate logistic regression model for false positive exams. RESULTS: A total of 5835 LCS CTs were included from 3735 patients. Lung cancer was diagnosed in 142 cases (2%). Of the LCS CTs, 905 (16%) were positive by Lung-RADS, and 766 (13%) represented false positives. Logistic regression analysis showed that screening institution (odds ratios [OR] 0.91 - 2.43), baseline scan (OR 1.43), radiologist experience (OR 0.59), patient age (OR 2.08), diagnosis of chronic obstructive pulmonary disease (OR 1.34), presence of emphysema (OR 1.32), and income level (OR 0.43) were significant predictors of false positives. CONCLUSION: A number of patient-specific and site/radiologist-specific factors influence the false positive rate in CT LCS. In particular, radiologists with less experience had a higher false positive rate. Screening programs may wish to develop quality assurance programs to compare the false positive rates of their radiologists to national benchmarks.

Cost-Effectiveness of Follow-Up Ultrasound for Incidental Thyroid Nodules on CT.

BACKGROUND. Thyroid nodules are common incidental findings on CT. Existing professional society recommendations, based primarily on expert opinion, advise follow-up ultrasound for nodules above size cutoffs in patients of all ages. OBJECTIVE. The purpose of this study was to use a simulation model to evaluate the cost-effectiveness of current recommendations and of other age- and size-based follow-up strategies for thyroid nodules incidentally detected on CT. METHODS. By using a simulation model with 1,000,000 adults with nodules measuring 40 mm or less that have no suspicious features, we evaluated size cutoffs from 5 to 25 mm in patients younger than an age maximum from 25 to 65 years, as well as follow-up versus no follow-up for patients above the age maximum. For each strategy, patient survival was determined by disease-specific and baseline mortality rates and surgical mortality. Costs and quality-adjusted life years (QALYs) were tabulated. A probabilistic sensitivity analysis was performed with varying model parameters. RESULTS. All cost-effective strategies recommended no follow-up for patients above the age cutoffs (which varied from 25 to 65 years). In the base-case simulation, 10 strategies were cost-effective at a willingness-to-pay threshold of $100,000/QALY. Of these, the strategy yielding the highest QALYs was follow-up for patients under 60 years old with nodules 10 mm or larger and no follow-up for patients 60 years old or older, with an incremental cost-effectiveness ratio of $50,196/QALY (95% CI, $39,233-67,479). In the probabilistic sensitivity analysis, if the 10-year disease-specific survival of patients with untreated cancer was more than 94% of patients with treated cancer, then no follow-up for any nodules was optimal. CONCLUSION. Follow-up ultrasound for thyroid nodules incidentally detected on CT is likely not cost-effective in older patients. Follow-up for most thyroid nodules in younger patients may be cost-effective. CLINICAL IMPACT. Future societal recommendations may account for the limited benefit of obtaining follow-up for incidental thyroid nodules on CT in older patients.

Cost-effectiveness Evaluation of the 2021 US Preventive Services Task Force Recommendation for Lung Cancer Screening.

IMPORTANCE: The US Preventive Services Task Force (USPSTF) issued its 2021 recommendation on lung cancer screening, which lowered the starting age for screening from 55 to 50 years and the minimum cumulative smoking exposure from 30 to 20 pack-years relative to its 2013 recommendation. Although costs are expected to increase because of the expanded screening eligibility criteria, it is unknown whether the new guidelines for lung cancer screening are cost-effective. OBJECTIVE: To evaluate the cost-effectiveness of the 2021 USPSTF recommendation for lung cancer screening compared with the 2013 recommendation and to explore the cost-effectiveness of 6 alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years and an ending age for screening of 80 years but varied the starting ages for screening (50 or 55 years) and the number of years since smoking cessation (≤15, ≤20, or ≤25). DESIGN, SETTING, AND PARTICIPANTS: A comparative cost-effectiveness analysis using 4 independently developed microsimulation models that shared common inputs to assess the population-level health benefits and costs of the 2021 recommended screening strategy and 6 alternative screening strategies compared with the 2013 recommended screening strategy. The models simulated a 1960 US birth cohort. Simulated individuals entered the study at age 45 years and were followed up until death or age 90 years, corresponding to a study period from January 1, 2005, to December 31, 2050. EXPOSURES: Low-dose computed tomography in lung cancer screening programs with a minimum cumulative smoking exposure of 20 pack-years. MAIN OUTCOMES AND MEASURES: Incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) of the 2021 vs 2013 USPSTF lung cancer screening recommendations as well as 6 alternative screening strategies vs the 2013 USPSTF screening strategy. Strategies with a mean ICER lower than $100 000 per QALY were deemed cost-effective. RESULTS: The 2021 USPSTF recommendation was estimated to be cost-effective compared with the 2013 recommendation, with a mean ICER of $72 564 (range across 4 models, $59 493-$85 837) per QALY gained. The 2021 recommendation was not cost-effective compared with 6 alternative strategies that used the 20 pack-year criterion. Strategies associated with the most cost-effectiveness included those that expanded screening eligibility to include a greater number of former smokers who had not smoked for a longer duration (ie, ≤20 years and ≤25 years since smoking cessation vs ≤15 years since smoking cessation). In particular, the strategy that screened former smokers who quit within the past 25 years and began screening at age 55 years was associated with screening coverage closest to that of the 2021 USPSTF recommendation yet yielded greater cost-effectiveness, with a mean ICER of $66 533 (range across 4 models, $55 693-$80 539). CONCLUSIONS AND RELEVANCE: This economic evaluation found that the 2021 USPSTF recommendation for lung cancer screening was cost-effective; however, alternative screening strategies that maintained a minimum cumulative smoking exposure of 20 pack-years but included individuals who quit smoking within the past 25 years may be more cost-effective and warrant further evaluation.

Cost-Effectiveness of Treatment Thresholds for Subsolid Pulmonary Nodules in CT Lung Cancer Screening.

Background Guidelines such as the Lung CT Screening Reporting and Data System (Lung-RADS) are available for determining when subsolid nodules should be treated within lung cancer screening programs, but they are based on expert opinion. Purpose To evaluate the cost-effectiveness of varying treatment thresholds for subsolid nodules within a lung cancer screening setting by using a simulation model. Materials and Methods A previously developed model simulated 10 million current and former smokers undergoing CT lung cancer screening who were assumed to have a ground-glass nodule (GGN) at baseline. Nodules were allowed to grow and to develop solid components over time according to a monthly cycle and lifetime horizon. Management strategies generated by varying treatment thresholds, including the solid component size and use of the Brock risk calculator, were tested. For each strategy, average U.S. costs and quality-adjusted life years (QALYs) gained per patient were computed, and the incremental cost-effectiveness ratios (ICERs) of those on the efficient frontier were calculated. One-way and probabilistic sensitivity analyses of results were performed by varying several relevant parameters, such as treatment costs or malignancy growth rates. Results Variants of the Lung-RADS guidelines that did not treat pure GGNs were cost-effective. Strategies based on the Brock risk calculator did not reach the efficient frontier. The strategy with the highest QALYs under a willingness-to-pay threshold of $100 000 per QALY included no treatment of GGNs and a threshold of 4-mm solid component size for treatment of subsolid nodules. This strategy yielded an ICER of $52 993 per QALY (95% CI: 44 407, 64 372). Probabilistic sensitivity analysis showed this was the optimal strategy under a range of parameter variations. Conclusion Treatment of pure ground-glass nodules was not cost-effective. Strategies that use modifications of the Lung CT Screening Reporting and Data System guidelines were cost-effective for treating part-solid nodules; an optimal threshold of 4 mm for the solid component yielded the most quality-adjusted life years. © RSNA, 2021 Online supplemental material is available for this article.

Cost-Effectiveness of Management Algorithms for Lung-RADS Category 4 Nodules.

PURPOSE: To evaluate nodule management guidelines in a simulated cohort of Lung Reporting and Data System (Lung-RADS) 4 nodules based on real-world data. MATERIALS AND METHODS: In this retrospective study, 100 000 patients were simulated from 151 patients with Lung-RADS 4 nodules (from January 2010 to August 2018). Each patient in the simulation was managed with each algorithm, and health outcomes were accumulated based on interventions and delays to cancer diagnosis. If the algorithm missed a cancer, it was diagnosed at the next annual screening round, although it would grow in the interim. Patient age-specific or cancer-specific mortality was assigned depending on whether the nodule was malignant, and quality-adjusted life years (QALYs) were calculated. Costs of interventions and cancer treatment were accumulated. One-way sensitivity analyses were performed. RESULTS: The most effective algorithm was the British Thoracic Society (BTS; 10.041 QALYs), followed by the American College of Chest Physicians (10.035 QALYs) and Lung-RADS (10.021 QALYs). Only the BTS and Lung-RADS were on the efficient frontier, with an incremental cost-effectiveness ratio (ICER) of $52 634 (95% CI: $45 122, $60 619). Under nearly all sensitivity analyses, the only algorithms on the efficient frontier were BTS and Lung-RADS. The ICERs for BTS versus Lung-RADS were under $100 000 for all scenarios except an increased life expectancy in patients without cancer, in which case the ICER was $109 273. CONCLUSION: The BTS algorithm and Lung-RADS were cost-effective for managing category 4 nodules, with BTS yielding greater QALYs.Supplemental material is available for this article.© RSNA, 2021See also the commentary by Elicker in this issue.