我国结直肠癌筛查卫生经济学证据系统更新：2009－2018

目的 系统更新中国大陆结直肠癌筛查的卫生经济学评价证据。方法 基于2015年发表的系统综述（2004-2014年），扩大检索数据库范围（PubMed、EMbase、The Cochrane Library、Web of Science、中国知网、万方数据知识服务平台、维普中文科技期刊数据库和中国生物医学文献数据库），延展时间至2018年12月，重点呈现近10年证据（2009-2018年）。系统摘录研究基本特征及主要结果。成本数据采用医疗保健类居民消费价格指数均贴现至2017年，计算增量成本效果比（ICER）与对应年份全国人均GDP的比值。结果 最终纳入12篇文献（新增8篇），其中9篇基于人群（均为横断面研究），3篇基于模型。起始年龄多为40岁（7篇），筛查频率多为终生1次（11篇）。筛查技术涉及问卷评估、免疫法粪便隐血试验和结肠镜。经济学评价指标以每检出1例结直肠癌的成本最为常见，中位数（范围，筛查方案数）为52 307元（12 967~3 769 801，n=20）；每检出1例腺瘤的成本为9 220元（1 859~40 535，n=10）。3篇文献报告了与不筛查相比，每挽救1个生命年的成本，其ICER与GDP比值为0.673（-0.013~2.459，n=11），是WHO认为的非常经济有效；不同筛查技术间及不同频率间该比值的范围重叠较大，但起始年龄50岁（0.002，-0.013~0.015，n=3）比40岁（0.781，0.321~2.459，n=8）筛查方案更经济有效。结论 人群研究提示腺瘤检出成本仅为癌症检出成本的1/6，有限的ICER证据提示在我国人群开展结直肠癌筛查经济有效；尽管最优初筛技术无法定论，但初步提示筛查起始年龄50岁优于40岁。未见随机对照试验评价等高级别证据。     

河南省城市地区低剂量螺旋CT肺癌筛查依从性及其影响因素分析

目的 评价2013-2017年河南省城市地区肺癌高危人群的低剂量螺旋CT（LDCT）筛查依从性并探索可能的影响因素。方法 采取整群抽样的方法,选取河南省40～74岁城市户籍居民进行癌症危险因素调查和肺癌风险评估,并对评估出的肺癌高危人群进行LDCT检查。采用χ²检验比较不同特征人群的LDCT筛查参与率差异,并采用Cochran-Armitage趋势检验对筛查参与率的时间趋势进行检验;采用多因素logistic回归模型分析LDCT筛查参与率的影响因素。结果 共纳入符合研究要求的肺癌高危人群35 672例,其中13 383例接受了LDCT检查,总体参与率为37.52%。LDCT筛查的参与率存在显著的地区和时间差异：最高和最低城市的参与率分别为38.47%和26.73%;2013-2014年的总体筛查参与率最低,为29.22%,2014-2015年最高,为43.30%（P<0.05）,且随着筛查年份增加,筛查参与率逐渐增加（P<0.001）。多因素logistic回归分析显示,女性、45～69岁、具有初/高中文化程度、既往吸烟、正在饮酒或既往饮酒、不经常体育锻炼、有肺结核史、有慢性支气管炎史、有肺气肿史、有哮喘支气管扩张史和有肺癌家族史的人群更愿意接受LDCT检查（均P<0.05）。结论 河南省城市肺癌高危人群的LDCT筛查参与率仍不高。针对本研究识别出的特定高危人群采取相应的干预措施可能会在将来的肺癌筛查中提升LDCT检查的总体依从性。     

我国乳腺癌筛查卫生经济学研究的系统评价

目的 了解我国大陆地区乳腺癌筛查的卫生经济学评价进展。方法 系统检索PubMed、中国知网、万方数据知识服务平台和维普网1995年1月至2015年12月收录文献,对纳入研究基本信息、人群项目参与率及检出率、模型研究方法学、经济学评价方法及结果等信息进行摘录和比较,采用卫生经济学评价报告规范（CHEERS）评价报告质量（总分24分）。结果 共检索356篇文献,最终纳入13篇,均发表于近4年（2012-2015年）,其中11篇基于人群、3篇基于模型研究。筛查起始年龄为18～45岁,终止年龄均≥59岁;筛查技术包括临床检查、超声和钼靶单一或联合筛查。有7篇报道了研究角度,其中为政府等服务提供方5篇,社会角度2篇;仅有5篇研究进行了成本和（或）效果贴现。11篇成本-效果分析中,有9篇提供了评价指标检出1例乳腺癌的成本,为5.0～229.3（M=14.5）万元。以质量调整生命年（QALY）或伤残调整生命年（DALY）为指标的成本-效用分析仅4篇,相应增量成本效果比（ICER）为0.3万元～27.1万元（2015年我国人均GDP为4.9万元）。13篇文献平均得分14.5（9.5～21.0）分,总分24分,其中研究角度、贴现率、ICER及不确定性等维度得分较低。结论 我国大陆地区乳腺癌筛查的经济学研究尚处于起步阶段,尤其是模型研究;各研究间方法及结果可比性一般,报告质量有待加强。应从社会角度全面核算成本后对筛查项目开展以QALY或DALY为指标的成本-效用分析。     

不同免疫程序接种2剂麻疹-流行性腮腺炎-风疹联合减毒活疫苗的卫生经济学评价

目的 比较不同免疫程序接种2剂麻疹-流行性腮腺炎-风疹联合减毒活疫苗（MMR）的卫生经济学评价指标差异。方法 对浙江省假定的70万出生队列人群随访一个生命周期（75年），采用增量成本效果比（ICER）、增量成本效益比（ICBR）和增量净收益（INB）方法，在设定条件下比较当前国家免疫规划中MMR接种策略（策略1）、调整为8和18月龄均接种MMR（策略2）以及额外再增加4岁组接种MMR（策略3）。调整研究设定的主要参数，利用敏感性分析评价研究结果的稳定性。结果 与策略1相比，策略2和3的ICER（元/例）分别为2 012.51：1和4 238.72：1，ICBR分别为1：3.14和1：1.58，INB分别为2 127.78万元和927.65万元。分析接种率、疫苗保护效果、发病风险、疾病成本、疫苗价格和接种成本等指标敏感性，其卫生经济学评价结果一致，各指标变化幅度<20%。结论 在国家免疫规划的基础上，改用8月龄接种MMR比4岁组增加1剂MMR的策略更具卫生经济学意义。     

低剂量螺旋CT和痰液基薄层细胞学联合筛查社区肺癌高危人群的研究

目的 评价低剂量螺旋CT（low-dose computed tomography, LDCT）和痰液基薄层细胞学检测（thinprep cytologic test, TCT）对社区肺癌高危人群的联合筛查效果。方法 对2013年8月~2014年9月在社区招募符合本研究高危人群定义的3 708名东莞本地居民进行肺癌筛查。肺癌高危人群定义为符合下列任何一项的40岁以上者:20包年以上的吸烟史,肺癌家族史,肺部既往病史,职业接触史或被动吸烟史。发现至少一个直径≥4 mm 非钙化结节为LDCT筛查的阳性结果;细胞学重度不典型增生或镜检可见癌细胞为TCT检查的阳性结果。结果 LDCT肺部结节的检出率为12.59%（467/3 708）。经病理证实,LDCT筛查阳性人群中共确诊肺癌56例,检出率为1.51%（56/3 708）。TCT的阳性检出率为1.91%（71/3 708）。TCT阳性人群中共确诊肺癌36例,肺癌检出率为0.97%（36/3 708）。本次联合筛查共确诊肺癌58例,非小细胞肺癌41例,其中0～Ⅰ 期22例,早期诊断率为53.66%（22/41）。结论 LDCT和TCT联合筛查肺癌高危人群有助于提高肺癌的早期诊断率和检出率,降低筛查的假阳性比例。     

HIV自检模式在男男性行为者中的成本效果分析

目的 分析珠海市MSM中HIV自我检测（HIVST）模式和现场HIV快速检测（HIV-RDT）模式的成本效果和支付意愿,为政府合理配置卫生资源提供参考依据。方法 以卫生服务提供者的视角,收集珠海市在2019年1-9月MSM参与两种HIV检测模式的成本投入和效果产出,采用TreeAge Pro 2019软件构建10 000名MSM队列决策树模型,测算成本效果比（CER）和增量成本效果比（ICER）,以敏感性分析模型中各参数的不确定性,绘制成本效果可支付曲线评价策略的可支付性。结果 珠海市男同社会组织通过互联网+社交媒体动员参与HIVST和现场HIV-RDT的MSM人次数为2 303 vs.816,发现HIV筛查阳性者人数为33 vs.35,筛查阳性率为1.7% vs.4.3%。每筛查1例的成本为60.45元vs.240.43元,每发现1例筛查阳性的成本为4 218元vs.5 606元。决策树模型运行结果显示,每检测1例MSM的平均费用为44.67元vs.148.42元,ICER为负值。当发现1例HIV筛查阳性支付意愿低于6 528元时,HIVST更具成本效果的选择;当投入高于该阈值时,现场HIV-RDT是更具成本效果的选择。结论 珠海市现行的HIVST模式是具有经济学价值的公共卫生项目,决策者应加大社会组织扶持力度,推广HIVST在MSM中的应用。     

起始年龄对结直肠癌高危人群进展期病变检出的影响研究

目的 比较不同筛查起始年龄对结直肠癌高危人群的进展期病变检出的影响。方法 基于浙江省嘉善县结直肠癌早诊早治筛查项目,以2007年1月至2020年12月两轮筛查中初筛阳性的结直肠癌高危人群为研究对象,剔除信息不全者后,最终分别纳入27 130例和31 205例。采用基于广义加性模型的样条分析拟合高危人群进展期病变检出率的年龄变化趋势。进一步计算50、45和40岁3种不同起始年龄的进展期病变检出率和需镜检人数,并采用χ²拟合优度检验比较检出率差异。结果 两轮筛查分别有21 077例（77.69%）和25 249例（80.91%）参与了肠镜检查,分别检出结直肠进展期病变（癌与进展期腺瘤）1 097例（52.05‰）和1 151例（45.59‰）。结直肠癌和进展期腺瘤的检出率均随年龄增长而显著增加（趋势检验P<0.05）,且第一轮检出率显著高于第二轮（P<0.05）。分别以50、45和40岁为起始年龄的结直肠进展期病变检出率在第一轮筛查中依次为61.11‰、56.14‰和52.05‰,在第二轮中依次为49.10‰、46.75‰和45.59‰。χ²拟合优度检验表明,以40岁为起始年龄的进展期病变检出率显著低于以50岁为起始年龄的进展期病变检出率（P<0.05）。相应地,50、45和40岁3种起始年龄每检出1例进展期病变的需镜检人数在第一和第二轮筛查中分别为17、18、20人和21、22、22人。结论 结直肠进展期病变检出率随年龄增长而增大。因此,筛查起始年龄提前会使进展期病变检出率减小,但实际差异有限。     

胃癌高危人群胃镜监测策略的卫生经济学评价

目的基于年龄和性别,评价胃癌高危人群胃镜监测的卫生经济学效果,确定目前经济水平下对胃癌高危人群进行长期胃镜监测的最优策略。方法构建基于胃癌自然史的Markov模型,模拟评估两种筛查方案:每年筛查一次和每两年筛查一次,并将没有胃镜筛查作为对照方案,计算质量调整寿命年、增量成本效果比等经济学指标。结果筛查起始年龄为40岁、45岁、50岁时,每年筛查一次的增量成本效果比(ICER)(元/QALYs)分别为23604.7、31287.4、44439.2,均小于支付意愿52000,且每年筛查一次的质量调整寿命年(QALYs)均大于每两年筛查一次和不筛查策略,故胃镜监测的最优策略为每年筛查一次。筛查年龄55岁时,每年筛查一次和每两年筛查一次的ICER(元/QALYs)分别为71382.3、60537.6,不具有成本效果,故55岁后筛查效果较差。不同性别分组不改变最优策略的选择。结论随着筛查年龄的不断增大,三种策略的成本和效果均不断降低,55岁前每年筛查一次为胃镜监测的最优策略。     

我国消除丙型肝炎的普通人群HCV检测策略的成本效果分析

目的 分析我国消除丙型肝炎（丙肝）的普通人群HCV检测策略的成本效果,明确最佳成本效果的HCV检测年龄。方法 运用TreeAge pro 2019软件构建决策树马尔科夫模型,以1年为周期,模拟10万名20~59岁各年龄组人群HCV检测和治疗结果,以全社会角度分析策略间比较的成本效果和效益。效果指标为增量成本效果比（ICER）,效益指标为净货币效益（NMB）,以我国2022年人均国内生产总值（85 698元）为意愿支付阈值。通过单因素敏感性分析和概率敏感性分析评估结果可靠性。结果 在20~59岁人群HCV检测有成本效果,在40~49岁年龄组进行HCV检测成本效果最佳。20~59岁年龄组人群HCV检测策略与未HCV检测策略比较,增量成本为161.24元/人,增量效用为0.003 6质量调整寿命年（QALYs）/人,ICER为45 197.26元/QALY,ICER小于意愿支付阈值,具有成本效果。各年龄组人群HCV检测策略与未HCV检测策略比较,ICER为42 055.06~53 249.43元/QALY,NMB为96.52~169.86元/人,其中40~49岁年龄组的ICER最低,NMB最高。单因素敏感性分析结果显示,贴现率、丙肝抗体（抗-HCV）检测成本、人群抗-HCV阳性率和直接抗病毒药物治疗成本对经济学评价影响较大,但改变参数取值,结论不变。概率敏感性分析结果表明模型分析结果稳定。结论 医疗机构探索动员20~59岁普通人群进行HCV检测具有较好的成本效果,以40~49岁年龄组人群的HCV检测成本效果最佳。在我国普通人群中实施HCV检测的“愿检尽检”策略,能降低人群丙肝疾病负担。     

宫颈癌筛查方法及其筛查起始年龄的卫生经济学评价

目的 <\b>对宫颈癌多种筛查方案终生筛查一次的效果进行卫生经济学评价,并探讨最具有成本效果的筛查起始年龄.方法 <\b>在农村地区选择醋酸/碘染色肉眼观察检查(VIA/VILI)、传统巴氏细胞学检测(Pap Smear)和简易人乳头瘤病毒(HPV) DNA检测(careHPV)3种筛查方法,城市地区选择PAP Smear、液基细胞学检测(LBC)、careHPV、HPV DNA检测(HC2)和LBC联合HC2检测(LBC+HC2)5种筛查方法.运用Markov模型,预测在不同筛查起始年龄终生筛查一次的远期流行病学和卫生经济学效果.结果 <\b>在农村和城市地区,各筛查方案队列人群20年后挽救的累积生命年分别为277.97年/10万人至2727.53年/10万人和134.02年/10万人至1446.84年/10万人;与对照组相比,各筛查方案每挽救一个生命年的成本分别在1520.99 ～ 2453.74元和3847.35～44 570.35元之间;增量成本效果分析显示,农村地区的优势方案依次为careHPV 40岁和careHPV 30岁起始筛查方案,城市地区的优势方案依次为careHPV 40岁、careHPV 30岁、HC2 30岁和LBC+HC2 30岁起始筛查方案.结论 <\b>如妇女终生接受一次筛查,农村和城市地区所有评价方案均具有成本效果,careHPV 40岁起始筛查是中国农村和城市地区最具有成本效果的筛查方案.     

Cost-effectiveness of HPV vaccination compared with Pap smear screening on a national scale: a literature review

Recommendations for worldwide use of human papillomavirus (HPV) vaccine are increasing. This study conducted a systematic review of articles related to cost-effectiveness analysis of wide-range HPV vaccination programs compared with Pap smear screening published before August 2007. Eight articles were identified using predefined inclusion and exclusion criteria. After excluding two outliers, the range of incremental cost-effectiveness ratios (ICERs) from six articles is between $16,600 and $27,231 per quality-adjusted life year (QALY) gained. The World Health Organization's guideline that compares incremental cost-effectiveness ratios (ICERs) with per capita Gross Domestic Product (GDP) was used to determine whether nation-wide application of HPV vaccine would be cost-effective. The HPV vaccination program is cost-effective in only 46 countries where per capita GDP is high. Further cost-effectiveness studies in developing and third-world countries are needed for making policy decisions.     

Variation in Model-Based Economic Evaluations of Low-Dose Computed Tomography Screening for Lung Cancer: A Methodological Review

ObjectivesThere is significant heterogeneity in the results of published model-based economic evaluations of low-dose computed tomography (LDCT) screening for lung cancer. We sought to understand and demonstrate how these models differ.MethodsAn expansion and update of a previous systematic review (N = 19). Databases (including MEDLINE and Embase) were searched. Studies were included if strategies involving (single or multiple) LDCT screening were compared with no screening or other imaging modalities, in a population at risk of lung cancer. More detailed data extraction of studies from the previous review was conducted. Studies were critically appraised using the Consensus Health Economic Criteria list.ResultsA total of 16 new studies met the inclusion criteria, giving a total of 35 studies. There are geographic and temporal differences and differences in screening intervals and eligible populations. Studies varied in the types of models used, for example, decision tree, Markov, and microsimulation models. Most conducted a cost-effectiveness analysis (using life-years gained) or cost-utility analysis. The potential for overdiagnosis was considered in many models, unlike with other potential consequences of screening. Some studies report considering lead-time bias, but fewer mention length bias. Generally, the more recent studies, involving more complex modeling, tended to meet more of the critical appraisal criteria, with notable exceptions.ConclusionsThere are many differences across the economic evaluations contributing to variation in estimates of the cost-effectiveness of LDCT screening for lung cancer. Several methodological factors and evidence needs have been highlighted that will require consideration in future economic evaluations to achieve better agreement.     

Cost-effectiveness of human papillomavirus vaccination in girls living in Latin American countries: A systematic review and meta-analysis

BackgroundCervical cancer is a major public health problem in Latin America. Cost-effectiveness studies help stakeholders with decisions regarding human papillomavirus (HPV) vaccination programs, one of the main prevention measures. Our objective was to synthesize the results of cost-effectiveness studies of HPV vaccination in girls, to understand factors influencing cost-effectiveness in the region.MethodsWe systematically searched databases as well as repositories from conferences, Ministries of Health and Health Technology Assessment offices. Incremental cost-effectiveness ratios (ICERs) were extracted, with data converted to international dollars (I$) and inflated to 2019 values. We used the gross domestic product per capita as threshold for judging the cost-effectiveness of vaccination. We calculated the geometric mean ICER by type of vaccine, whether screening (cytology or HPV test) was used as comparator, effectiveness measure, perspective, source of funding, year of cost, and country.ResultsWe found 24 studies. Despite the methodological differences, most studies concluded that HPV vaccination of girls in Latin American countries was either cost-saving or cost-effective. The mean ICER was I$ 3,804 for the bivalent vaccine, I$ 640 for the quadrivalent and I$ 358 for a generic HPV-16/18 vaccine. The mean ICER was lower in the studies that used HPV DNA test instead of cytology (I$ 122 vs I$ 1,841) as comparator; used the societal perspective (I$ 235 vs. I$ 1,986); were funded by non-profit sources instead of by pharmaceutical industry (I$ 421 vs. I$ 2,676); and used costs obtained prior to 2008 (I$ 365 vs I$ 1,415). We observed great variation in the mean ICERs by effectiveness measure (I$ 402 for per disability adjusted life years, I$ 461 for life year saved, and I$ 1,795 for quality adjusted life years).ConclusionsMost studies concluded that HPV vaccination of girls in Latin America countries was cost-saving or cost-effective, despite heterogeneity between models.     

Cost-Effectiveness Analyses of Lung Cancer Screening Strategies Using Low-Dose Computed Tomography: a Systematic Review

Background

Lung cancer screening with low-dose computed tomography (LDCT) has been shown to deliver appreciable reductions in mortality in high-risk patients. However, in an era of constrained medical resources, the cost-effectiveness of such a program needs to be demonstrated.

Objective

The aim of this study was to systematically review the literature analyzing the cost-effectiveness of lung cancer screening using LDCT.

Methods

We searched MEDLINE, EMBASE, EBM Reviews—Health Technology Assessment, the National Health Service Economic Evaluation Database (NHS-EED), and the Cochrane Database of Systematic Reviews. Due to technological progress in CT, we limited our search to studies published between January 2000 and December 2014. Our search returned 393 unique results. After removing studies that did not meet our inclusion criteria, 13 studies remained. Costs are presented in 2014 US dollars (US$).

Results

The results from the economic evaluations identified in this review were varied. All identified studies reported outcomes using either additional survival (life-years gained) or quality-adjusted life-years (QALYs gained). Results ranged from US$18,452 to US$66,480 per LYG and US$27,756 to US$243,077 per QALY gained for repeated screening. The results of cost-effectiveness analyses were sensitive to several key model parameters, including the prevalence of lung cancer, cost of LDCT for screening, the proportion of lung cancer detected as localized disease, lead time bias, and, if included, the characteristics of a smoking cessation program.

Conclusions

The cost-effectiveness of a lung cancer screening program using LDCT remains to be conclusively resolved. It is expected that its cost-effectiveness will largely depend on identifying an appropriate group of high-risk subjects.

     

Cost-Effectiveness of Baseline Low-Dose Computed Tomography Screening for Lung Cancer: The Israeli Experience

ObjectiveReduced mortality with low-dose computed tomography (LDCT) lung cancer screening was demonstrated in a large randomized controlled study of high-risk individuals. Cost-effectiveness must be assessed before routine LDCT screening is considered. We aimed to evaluate the cost-effectiveness of LDCT lung cancer screening in Israel.MethodsA decision analytic framework was used to evaluate the decision to screen or not screen from the health system perspective. The screening arm included 842 moderate-to-heavy smokers aged 45 years or older, screened at Hadassah-Hebrew University Medical Center from 1998 to 2004. In the usual-care arm, stage distribution and stage-specific life expectancy were obtained from the Israel National Cancer Registry data for 1994 to 2006. Lifetime stage-specific costs were estimated from medical records of patients diagnosed and treated at Hadassah Medical Center in the period 2003 to 2004. The analysis considered possible biases—lead time, overdiagnosis, and self-selection. Cost per quality-adjusted-life-year (QALY) gained by screening was estimated.ResultsBase-case incremental cost per QALY gained was $1464 (2011 prices). Extensive sensitivity analysis affirmed the low cost per QALY gained. The cost per QALY gained is lower than $10,000 with probability 0.937 and is lower than $20,000 with probability 0.978.ConclusionsOur analysis suggests that baseline LDCT lung cancer screening in Israel presents a good value for the money and should be considered for inclusion in the National List of Health Services financed publicly.     

Screening for lung cancer: A systematic review and meta-analysis

ObjectivesTo examine evidence on benefits and harms of screening average to high-risk adults for lung cancer using chest radiology (CXR), sputum cytology (SC) and low-dose computed tomography (LDCT).MethodsThis systematic review was conducted to provide up to date evidence for Canadian Task Force on Preventive Health Care (CTFPHC) lung cancer screening guidelines. Four databases were searched to March 31, 2015 along with utilizing a previous Cochrane review search. Randomized trials reporting benefits were included; any design was included for harms. Meta-analyses were performed if possible. PROSPERO #CRD42014009984.ResultsThirty-four studies were included. For lung cancer mortality there was no benefit of CXR screening, with or without SC. Pooled results from three small trials comparing LDCT to usual care found no significant benefits for lung cancer mortality. One large high quality trial showed statistically significant reductions of 20% in lung cancer mortality over a follow-up of 6.5 years, for LDCT compared with CXR. LDCT screening was associated with: overdiagnosis of 10.99–25.83%; 11.18 deaths and 52.03 patients with major complications per 1000 undergoing invasive follow-up procedures; median estimate for false positives of 25.53% for baseline/once-only screening and 23.28% for multiple rounds; and 9.74 and 5.28 individuals per 1000 screened, with benign conditions underwent minor and major invasive follow-up procedures.ConclusionThe evidence does not support CXR screening with or without sputum cytology for lung cancer. High quality evidence showed that in selected high-risk individuals, LDCT screening significantly reduced lung cancer mortality and all-cause mortality. However, for its implementation at a population level, the current evidence warrants the development of standardized practices for screening with LDCT and follow-up invasive testing to maximize accuracy and reduce potential associated harms.     

Should we screen for occupational lung cancer with low-dose computed tomography?

OBJECTIVE: The objective of this study was to assess the potential value of screening for occupational lung cancer through the use of low-dose computed tomography (LDCT). METHODS: A literature review of Medline was conducted to assess: 1) screening studies of occupational lung cancer that used LDCT; 2) screening studies of nonoccupational lung cancer that used LDCT; and 3) position papers of medical professional societies and nongovernmental health organizations that have addressed the value of screening for lung cancer with LDCT. RESULTS: No screening studies of occupational lung cancer with LDCT were uncovered; however, numerous observational and population-based studies have addressed the value of screening for lung cancer among cigarette smokers. Results of these studies are difficult to interpret in light of numerous biases associated with these types of studies. No randomized, controlled studies on screening for lung cancer have been published at this time. No professional, governmental, or nonprofit health organization recommends screening asymptomatic people at risk of lung cancer with LDCT at this time. CONCLUSION: In the absence of randomized, controlled studies that can address biases commonly encountered in observational and population-based studies, it is unclear whether LDCT reduces mortality from lung cancer. The National Cancer Institute is sponsoring a randomized, controlled study of over 50,000 current and former smokers with the results expected in 2009.     

Cost-Effectiveness of Targeted Genetic Testing for Breast and Ovarian Cancer: A Systematic Review

BackgroundTargeted genetic testing is a tool to identify women at increased risk of gynaecological cancer.ObjectiveThis systematic review evaluates the results and quality of cost-effectiveness modeling studies that assessed targeted genetic-based screen-and-treat strategies to prevent breast and ovarian cancer.MethodsUsing MEDLINE and databases of the Centre for Reviews and Dissemination, we searched for health economic modeling evaluations of targeted genetic-based screen-and-treat strategies to prevent inheritable breast and ovarian cancer (until August 2020). The incremental cost-effectiveness ratios (ICERs) were compared. Methodological variations were addressed by evaluating the model conceptualizations, the modeling techniques, parameter estimation and uncertainty, and transparency and validation of the models. Additionally, the reporting quality of each study was assessed.ResultsEighteen studies met our inclusion criteria. From a payer perspective, the ICERs of (1) BRCA screening for high-risk women without cancer ranged from dominating the no test strategy to an ICER of $21 700/quality-adjusted life years (QALY). In studies that evaluated (2) BRCA cascade screening (ie, screening of women with cancer plus their unaffected relatives) compared with no test, the ICERs were between $6500/QALY and $50 200/QALY. Compared with BRCA alone, (3) multigene testing in women without cancer had an ICER of $51 800/QALY (one study), while for (4) multigene-cascade screening the ICERs were $15 600/QALY, $56.500/QALY, and $69 600/QALY for women in the United Kingdom, Norway, and the United States, respectively (2 studies). More recently published studies showed a higher methodological and reporting quality.ConclusionsTargeted BRCA or multiple gene screening is likely to be cost-effective. Methodological variations could be decreased by the development of a reference model, which may serve as a tool for validation of present and future cost-effectiveness models.     

多基因遗传风险评分指导肺癌个体化筛查的前瞻性队列研究

目的探索如何利用遗传风险评分,制订个体化的肺癌筛查方案。方法利用中国慢性病前瞻性研究(CKB)队列10个地区100615例具有全基因组基因分型信息的样本,根据前期课题组发表的19个遗传变异构建肺癌多基因遗传风险评分PRS-19。以55岁且吸烟剂量30包/年人群的5年绝对发病风险为参考届值,在吸烟者和非吸烟者中分别计算不同遗传风险人群5年肺癌绝对发病风险随年龄和吸烟剂量的变化趋势,并绘制5年绝对发病风险分布图,从而判断不同遗传风险人群达到参考界值时的理论年龄或吸烟剂量。根据上述结果给出不同遗传风险人群参加肺癌筛查起始年龄的具体建议。结果CKB队列中55岁吸烟者,当吸烟量为30包/年时,5年内发生肺癌的绝对风险为0.67%。在吸烟者中,随着遗传风险增加,其5年绝对发病风险呈不断上升趋势,对于高遗传风险人群应降低筛查起始年龄,遗传风险最高的1%人群建议从50岁开始进行筛查;若保持筛查起始年龄55岁不变,则应在高遗传风险人群中降低吸烟剂量标准;不管累积吸烟剂量为多少,遗传风险最高的1%人群都应纳入肺癌筛查。在非吸烟者中,高遗传风险人群同样具备筛查价值,建议遗传风险最高的1%人群从62岁起进行肺癌筛查,而对于遗传风险最低的5%人群,当年龄达到74岁时才可达到参考届值。结论对于不同遗传风险的个体,可采用个体化的肺癌筛查方案,对于高遗传风险的吸烟者可减小肺癌筛查起始年龄或吸烟剂量,而我国高遗传风险的非吸烟者同样具备筛查价值。