Title

Cost-Effectiveness of the International Late Effects of Childhood Cancer Guideline Harmonization Group Screening Guidelines to Prevent Heart Failure in Survivors of Childhood Cancer

Authors

Matthew J. Ehrhardt, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN.
Zachary J. Ward, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA.
Qi Liu, Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada.
Aeysha Chaudhry, Division of General Pediatrics, Boston Children's Hospital, Boston, MA.
Anju Nohria, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
William Border, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.
Joy M. Fulbright, Department of Pediatrics, The Children's Mercy Hospital, Kansas City, MO.
Daniel A. Mulrooney, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN.
Kevin C. Oeffinger, Department of Medicine, Duke University, Durham, NC.
Paul C. Nathan, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
Wendy M. Leisenring, Clinical Statistics and Cancer Prevention Programs, Fred Hutchinson Cancer Research Center, Seattle, WA.
Louis S. Constine, Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY.
Todd M. Gibson, Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN.
Eric J. Chow, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA.
Rebecca M. Howell, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX.
Leslie L. Robison, Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN.
Gregory T. Armstrong, Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN.
Melissa M. Hudson, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN.
Lisa Diller, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA.
Yutaka Yasui, Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN.
Saro H. Armenian, Department of Population Sciences, City of Hope Medical Center, Duarte, CA.
Jennifer M. Yeh, Division of General Pediatrics, Boston Children's Hospital, Boston, MA.

Abstract

PURPOSE: Survivors of childhood cancer treated with anthracyclines and/or chest-directed radiation are at increased risk for heart failure (HF). The International Late Effects of Childhood Cancer Guideline Harmonization Group (IGHG) recommends risk-based screening echocardiograms, but evidence supporting its frequency and cost-effectiveness is limited. PATIENTS AND METHODS: Using the Childhood Cancer Survivor Study and St Jude Lifetime Cohort, we developed a microsimulation model of the clinical course of HF. We estimated long-term health outcomes and economic impact of screening according to IGHG-defined risk groups (low [doxorubicin-equivalent anthracycline dose of 1-99 mg/m and/or radiotherapy < 15 Gy], moderate [100 to < 250 mg/m or 15 to < 35 Gy], or high [≥ 250 mg/m or ≥ 35 Gy or both ≥ 100 mg/m and ≥ 15 Gy]). We compared 1-, 2-, 5-, and 10-year interval-based screening with no screening. Screening performance and treatment effectiveness were estimated based on published studies. Costs and quality-of-life weights were based on national averages and published reports. Outcomes included lifetime HF risk, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs). Strategies with ICERs < $100,000 per QALY gained were considered cost-effective. RESULTS: Among the IGHG risk groups, cumulative lifetime risks of HF without screening were 36.7% (high risk), 24.7% (moderate risk), and 16.9% (low risk). Routine screening reduced this risk by 4% to 11%, depending on frequency. Screening every 2, 5, and 10 years was cost-effective for high-risk survivors, and every 5 and 10 years for moderate-risk survivors. In contrast, ICERs were > $175,000 per QALY gained for all strategies for low-risk survivors, representing approximately 40% of those for whom screening is currently recommended. CONCLUSION: Our findings suggest that refinement of recommended screening strategies for IGHG high- and low-risk survivors is needed, including careful reconsideration of discontinuing asymptomatic left ventricular dysfunction and HF screening in low-risk survivors.

Publication Title

Journal of clinical oncology : official journal of the American Society of Clinical Oncology

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