Lung cancer screening in risk groups Systematic review(s) of effectiveness and utility (part 1) Costs and budgetary consequences (part 2)

Lung cancer is one of the most common cancers in Austria, as well as the most frequent cancer-related cause of death in men and the second most frequent in women [1]. The risk factors for lung cancer include smoking in particular, but also (occupational) exposure to pollutants (e.g. radon, asbestos or particulate matter), as well as pre-existing diseases of the lung or bronchial system (e.g. chronic obstructive pulmonary disease [COPD] or fibrosis). A rough differentiation is made between small cell lung cancer and non-small cell lung cancer, whereby the small cell form usually has a significantly worse course.

Since a large prospective study on the screening of high-risk individuals for lung cancer (NELSON study [2]) concluded that cancer mortality could be reduced by 20% through low-dose computer tomography (LDCT), which is now also recommended in the USA, an intensive debate on the conditions under which screening with LDCT could be useful also started in Europe. Even before the results of the NELSON study were published, the establishment of lung cancer screening in risk groups was discussed nationally in expert circles, such as the Oncology Advisory Board, and the Austrian Society of Pneumology (ÖGP) together with the Austrian Society of Radiology (ÖRG) have set up a special task force for this purpose. However, others argue against the interpretation of the NELSON study that, although fewer people in the screening group died with a lung cancer diagnosis, there were more people with a different cancer diagnosis and there was no difference in overall mortality [3].

Aside from the interpretation of the available evidence, other factors are important in the implementation of risk group screening, such as screening intervals (1, 2 years); the way screening is organised (opportunistic vs. organised); information strategies to reach the target group; and an analysis of costs and budget implications, taking into account not only the resource consumption of the screening programme but also subsequent clinical treatments.

Project objective and research questions:

The aim of the project is to summarise the clinical evidence on lung cancer screening for risk groups and to obtain an overview of the elements of relevant costs as reported in publications on health economic evaluations and therefore to develop decision support for/against lung cancer screening in Austria.

The following research questions are to be answered in Part 1:

• RQ1: What is the benefit/risk of screening for lung cancer using low-dose chest computer tomography (LDCT) compared to no screening in individuals at elevated risk of lung cancer?
• RQ2: What is the benefit/risk of screening for lung cancer using biomarkers in addition to low-dose chest computer tomography (LDCT) compared to screening using LDCT alone in individuals at elevated risk of lung cancer?
• RQ3: What is the benefit/risk of annual screening/systematic screening for lung cancer compared to screening with longer intervals (2 years or longer) / opportunistic screening in individuals at elevated risk of lung cancer?
• RQ4: What is the best strategy to inform individuals in the target group about and/or to maximise participation in the screening for lung cancer?

The following research questions will be answered in Part 2:

• FF5: What are the relevant cost-components of lung cancer screening that have been considered in published health economic evaluations?
• FF6: Which methods have been used in the literature to estimate the cost of lung cancer screening and how should they be critically appraised?
• FF7: What are the results of existing economic evaluations of lung cancer screening in terms of cost-effectiveness and budget impact?

Method (Part 1):

Systematic review: Systematic literature search (in several databases), critical evaluation and synthesis

• RQ1: Further processing/editing of the IQWIG report (completion June 2020).
• RQ2 + RQ3: Overview of additional information on persons at risk, on screening intervals, type of organisation of screening from additionally searched sources and from the randomised controlled trials (RCTs) on which the IQWIG report is based.
• RQ4: Overview of information strategies for reaching the target groups.

Method (Part 2):

Systematic review of published international economic evaluations on lung cancer screening: systematic literature search and synthesis:

• FF5: Data extraction and overview of relevant cost-components as reported in health economic evaluations of lung cancer screening.
• FF6: Data extraction and critical appraisal of key methods used in available studies to estimate the cost of lung cancer screening.
• FF7: Data extraction and tabulation of cost-effectiveness and budget-impact estimates from international studies as well as a brief discussion of results, without transferring these results to the Austrian context.

Considering the geographic transferability of results from international cost-effectiveness and budget-impact analyses to the Austrian context does not form part of this study, as this is not considered feasible for the Austrian healthcare setting. Rather, this exercise may form the basis of an Austria-specific cost-effectiveness and/or budget-impact analysis that may be conducted as a follow-up study to this project.

Search strategies:

• Medline via Ovid, Embase, Cochrane (CENTRAL), INAHTA-Database, Centre for Research and Dissemination (CRD), EconLit, NHS Economic Evaluation Database
• Period of publication: Part 1: no limitation, Part 2: starting from 2005
• Hand search in references (if necessary using Scopus), Internet research

All process steps (literature selection, quality assessment, extraction) are performed independently by at least two scientists.

Inclusion criteria (PICO scheme) Part 1:

RQ1: What is the benefit/risk of screening for lung cancer using low-dose chest computer tomography (LDCT) compared to no screening in individuals at elevated risk of lung cancer?

RQ2: What is the benefit/risk of screening for lung cancer using biomarkers in addition to low-dose chest computer tomography (LDCT) compared to screening using LDCT alone in individuals at elevated risk of lung cancer?

RQ3: What is the benefit/risk of annual screening/systematic screening for lung cancer compared to screening with longer intervals (2 years or longer) / opportunistic screening in individuals at elevated risk of lung cancer?

RQ4: What is the best strategy to inform individuals in the target group about and/or to maximise participation in the screening for lung cancer?