• Vaibhav Kumar, Joshua T Cohen, David van Klaveren, Djøra I Soeteman, John B Wong, Peter J Neumann, and David M Kent.
• Tufts Medical Center, Boston, Massachusetts (V.K., J.T.C., J.B.W., P.J.N., D.M.K.).
• Ann. Intern. Med. 2018 Feb 6; 168 (3): 161-169.

BackgroundTargeting low-dose computed tomography (LDCT) for lung cancer screening to persons at highest risk for lung cancer mortality has been suggested to improve screening efficiency.ObjectiveTo quantify the value of risk-targeted selection for lung cancer screening compared with National Lung Screening Trial (NLST) eligibility criteria.DesignCost-effectiveness analysis using a multistate prediction model.Data SourcesNLST.Target PopulationCurrent and former smokers eligible for lung cancer screening.Time HorizonLifetime.PerspectiveHealth care sector.InterventionRisk-targeted versus NLST-based screening.Outcome MeasuresIncremental 7-year mortality, life expectancy, quality-adjusted life-years (QALYs), costs, and cost-effectiveness of screening with LDCT versus chest radiography at each decile of lung cancer mortality risk.Results Of Base Case AnalysisParticipants at greater risk for lung cancer mortality were older and had more comorbid conditions and higher screening-related costs. The incremental lung cancer mortality benefits during the first 7 years ranged from 1.2 to 9.5 lung cancer deaths prevented per 10 000 person-years for the lowest to highest risk deciles, respectively (extreme decile ratio, 7.9). The gradient of benefits across risk groups, however, was attenuated in terms of life-years (extreme decile ratio, 3.6) and QALYs (extreme decile ratio, 2.4). The incremental cost-effectiveness ratios (ICERs) were similar across risk deciles ($75 000 per QALY in the lowest risk decile to $53 000 per QALY in the highest risk decile). Payers willing to pay $100 000 per QALY would pay for LDCT screening for all decile groups.Results Of Sensitivity AnalysisAlternative assumptions did not substantially alter our findings.LimitationOur model did not account for all correlated differences between lung cancer mortality risk and quality of life.ConclusionsAlthough risk targeting may improve screening efficiency in terms of early lung cancer mortality per person screened, the gains in efficiency are attenuated and modest in terms of life-years, QALYs, and cost-effectiveness.Primary Funding SourceNational Institutes of Health (U01NS086294).

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