Cost-Effectiveness of Smoking Cessation Within a Lung Cancer Screening Program in Canada

Background: Demonstrated lung cancer mortality reductions through low-dose computed tomography (LDCT) has encouraged some jurisdictions to consider implementing organized LDCT screening. A retrospective analysis of former smokers in the National Lung Screening Trial (NLST) suggested that abstention from smoking coupled with low-dose computed tomography (LDCT) screening realized more mortality benefits than abstinence alone or LDCT alone. Aim: We evaluated the potential costs and cost-effectiveness of lung cancer screening with integrated smoking cessation using OncoSim-Lung (version 2.5), a microsimulation model led by the Canadian Partnership Against Cancer, with model development by Statistics Canada. Methods: We compared organized LDCT screening without smoking cessation to various plausible scenarios of screening with cessation. Assumptions included: annual screening of 55-74 year-old individuals with a 30-pack-yr history; a 42% participation rate reached over 10 years; cessation therapy (nicotine replacement therapy + varenicline + 12 weeks' counseling) at a cost of $490; and up to 10 cessation attempts, with a permanent quit rate of 5% per attempt. Cost-effectiveness was estimated with a lifetime horizon, health system perspective and 1.5% discount rate. Costs are in 2016 CAD. Results: OncoSim-Lung projected that LDCT screening integrated with cessation would cost approximately $76 million annually (undiscounted) from 2017 to 2036 in Canada. About 110 fewer lung cancer (LC) cases and 50 fewer LC deaths would occur annually, compared with screening without cessation. Additionally, many other smoking-related deaths would be prevented. Using a lifetime horizon, smoking cessation would cost $14,000/QALYs gained. In one-way sensitivity analysis, with a 72% participation rate there would be 260 fewer deaths, at $24,000/QALY. With a 10% quit rate, cost-effectiveness would improve to $6,000/QALY. A 50% increase in the cost of the cessation intervention would decrease cost-effectiveness to $22,000/QALY. Conclusion: Robust smoking cessation efforts within a LDCT screening program could save lives and be relatively cost-effective. Cancer control planners should consider integrating smoking cessation when implementing a lung cancer screening initiative.