• F Lennie Wong, Smita Bhatia, Wendy Landier, Liton Francisco, Wendy Leisenring, Melissa M Hudson, Gregory T Armstrong, Ann Mertens, Marilyn Stovall, Leslie L Robison, Gary H Lyman, Steven E Lipshultz, and Saro H Armenian.
• Ann. Intern. Med. 2014 May 20; 160 (10): 672-83.

BackgroundChildhood cancer survivors treated with anthracyclines are at high risk for asymptomatic left ventricular dysfunction (ALVD), subsequent heart failure, and death. The consensus-based Children's Oncology Group (COG) Long-Term Follow-up Guidelines recommend lifetime echocardiographic screening for ALVD.ObjectiveTo evaluate the efficacy and cost-effectiveness of the COG guidelines and to identify more cost-effective screening strategies.DesignSimulation of life histories using Markov health states.Data SourcesChildhood Cancer Survivor Study; published literature.Target PopulationChildhood cancer survivors.Time HorizonLifetime.PerspectiveSocietal.InterventionEchocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and β-blocker therapies after ALVD diagnosis.Outcome MeasuresQuality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure.Results Of Base Case AnalysisThe COG guidelines versus no screening have an ICER of $61 500, extend life expectancy by 6 months and QALYs by 1.6 months, and reduce the cumulative incidence of heart failure by 18% at 30 years after cancer diagnosis. However, less frequent screenings are more cost-effective than the guidelines and maintain 80% of the health benefits.Results Of Sensitivity AnalysisThe ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER.LimitationLifetime non-heart failure mortality and the cumulative incidence of heart failure more than 20 years after diagnosis were extrapolated; the efficacy of ACE inhibitor and β-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown).ConclusionThe COG guidelines could reduce the risk for heart failure in survivors at less than $100 000/QALY. Less frequent screening achieves most of the benefits and would be more cost-effective than the COG guidelines.

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