Cost-Effectiveness of the Children's Oncology Group Long-Term Follow-up Screening Guidelines for Childhood Cancer Survivors at Risk for Treatment-Related Heart Failure.
Wong, F. Lennie PhD; Bhatia, Smita MD, MPH; Landier, Wendy PhD, RN; Francisco, Liton BS; Leisenring, Wendy ScD; Hudson, Melissa M. MD; Armstrong, Gregory T. MD; Mertens, Ann PhD; Stovall, Marilyn PhD; Robison, Leslie L. PhD; Lyman, Gary H. MD, MPH; Lipshultz, Steven E. MD; Armenian, Saro H. DO, MPH
[Article]
Annals of Internal Medicine.
160(10):672-683, May 20, 2014.
(Format: HTML, PDF)
Background: Childhood 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.
Objective: To evaluate the efficacy and cost-effectiveness of the COG guidelines and to identify more cost-effective screening strategies.
Design: Simulation of life histories using Markov health states.
Data Sources: Childhood Cancer Survivor Study; published literature.
Target Population: Childhood cancer survivors.
Time Horizon: Lifetime.
Perspective: Societal.
Intervention: Echocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and [beta]-blocker therapies after ALVD diagnosis.
Outcome Measures: Quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure.
Results of Base-Case Analysis: The 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 Analysis: The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER.
Limitation: Lifetime 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 [beta]-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown).
Conclusion: The 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.
Primary Funding Source: Lance Armstrong Foundation and National Cancer Institute.
(C) 2014 American College of Physicians
