波兰肺癌筛查的成本和效果：15年预测

CostandeffectivenessoflungcancerscreeninginPoland:A15-year projection BrucePyenson,FSA, MAAAMichałKrzemińskiMonikaLis, CRSA Abstract Lung cancer is the leading cause of cancer death among men and women in Poland,with about 21,000deathsannually. Lung cancer screening (LCS) of high-risk populationshas been demonstrated to save lives by shifting thestage of diagnosis to earlier stages where there is a high cure rate. LCSwas recommended in the United Statesstartingin2013, and in 2022 the Council of the European Union encouraged EUMemberStatesto implement LCS.However, little analysis has been published on the potential impacts of LCS on the Polish population. Weconducted a 15-year projection of the high-risk Polish population associated with smoking history using theframework of a previously published model. Under conditions of full compliance to screening and establishedoutcomes of LCS, we estimate that over the 15-year period over a quarter of million life-years would be saved at anannualexpense ofon averagePLN4.9billion (approximately EUR1.1billion).Inthelong run the screening programis estimated to bringanaverage 3.74 extra life-years per cancer case diagnosed. While these results assume ideal compliance, the potential benefits of LCS in Poland are significant.Real-world lungcancerscreening programs havebeen shown to yield substantial improvements in early detection rates and treatment outcomes. Introduction Lung cancer(LC)is the leading cause of cancer death worldwidewitharound 2 millionincident casesand 1.8 milliondeaths (2020),1and, in 2021, there were about 20,600cases and 20,800deaths in Poland.2Early-stage lung cancersare highly curable, but most lung cancers are detected symptomatically at late stagesand most patients die within ayear or twoof diagnosis. Lung cancer screening (LCS) programs for high-risk patients using low-dose computedtomography (LDCT) have demonstrated dramatically improved survival, because LCS reliably shifts the stage ofdiagnosed LC to earlier stages. In late 2022 the Council of the European Union proposed new recommendations on cancer screening3thatincludes LCS. They encourage EU Member States to implement population-based, quality-assured screeningprograms with a stepwise approach: first assessing benefits and cost-effectiveness, including the potential impacton savings for health and long-term care systems, covering the target population and following evidence-based andup-to-date European guidelines. While LCS was officially recommended in the US startingin2013,4Croatia became the first European country toimplement LCS in October 2020. Croatia’s program targets people aged 50 to 75 with a smoking history of at least 30pack-years,5who currently smoke or have stopped smoking within the past 15 years.6National pilots have also beencarried out in Poland7and other European countries.InPoland, in2024,theNational Oncology Strategy forthe2020-2030periodwas amended to include an intention to introduce a publicly funded screening program for high-riskgroups to detect lung cancer starting from 2025.8 This article aims to contribute to the discussion of the costandeffectiveness of LCS in Poland by providing a forecastof screening and follow-up costs and mortality gains due to LCS. We consider several factors included in the Councilrecommendations such as epidemiology and incurred expenses. Other factors such as healthcare organizationalreadiness, service delivery and obtaining sufficiently high participation are not included in our analysis. Methods The analysis is based on a Markov model similar to the work of F. Hofer et al.,9which was used for Germany. Ourmodel was developed in R. We modelled the natural history of disease for the Polish target population of people aged50to75 with a smoking history of 20 pack-years, including people who quit smoking. The natural history componentof the lung cancer screening model simulatesanindividual’s progression of lung cancer over time in the absence ofscreening. The model uses a discrete-time Markov chain with a state for individuals with no lung cancer and variousstages representing different stages of lung cancer (I, II, IIIA, IIIB,IV). The model assumes a cycle length of threemonths. Disease progression probabilities are calibrated to align with observed data, encompassing age-dependentmortality rates and available information on lung cancer stage progression and survival. This component allows us tounderstand the natural course of the disease in the absence of screening. To estimate the impact of screening, screening processes and results are applied to individual trajectories. Weassumed that every eligible person from the target groupwhomeets age and smoking history criteria and has no priordiagnosis of lung cancer(includingthrough LCS), gets screened once a year. We also applied establishedprobabilities for clinical follow-up, including, for some individuals with important findings,arepeat of LCSbefore thenext annual screen. Eac