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Pairing smoking cessation with lung cancer screening may save lives
CA: A Cancer Journal for Clinicians  (IF508.702),  Pub Date : 2021-06-01, DOI: 10.3322/caac.21675
Mike Fillon

Key Points

  • Smoking cessation interventions at the time of lung cancer screening are cost-effective.
  • All of the cessation methods considered in this study were roughly equal in delivering benefits at similar costs.

A new study has found that offering smoking cessation interventions to current smokers simultaneously with lung cancer screenings provides more years of lifesaving benefit than screening alone at very little added expense. The study appeared in the Journal of the National Cancer Institute (JNCI; published online January 23, 2021. doi:10.1093/jnci/djab002).

The Centers for Medicare and Medicaid Services and guidelines from national health organizations, including the American Cancer Society, recommend that smoking cessation methods should be offered at the same time as lung cancer screening. However, in current lung screening clinical practice, cessation interventions are often omitted, in part because of uncertainty regarding their incremental benefit and cost-effectiveness.

In a related article written by many of the same authors and published at approximately the same time in the Journal of Thoracic Oncology (2020;15:1160-1169. doi:10.1016/j.jtho.2020.02.008), the researchers note that approximately 50% of screen-eligible individuals are current smokers, and they estimate that combined use of screening and a cessation intervention with a 10% quit rate might prevent 14% more lung cancer deaths than screening alone. The current JNCI study extends that research to estimate the cost-effectiveness of adding cessation interventions to lung cancer screening.

Rafael Meza, PhD, senior study author of the JNCI study and an associate professor at the Department of Epidemiology of the University of Michigan in Ann Arbor, Michigan, says that, “Our analysis [in the JNCI study], including comparisons between different approaches, shows that cessation programs within lung cancer screening greatly expand the benefits of lung cancer at a reasonable cost making it even more cost-effective.”

Study Details

For the JNCI study, the researchers used the Cancer Intervention and Surveillance Modeling Network simulation model as the basis to estimate the benefits, costs, and cost-effectiveness of 5 common cessation interventions at the time of lung cancer screening. Inputs to the model included 1 million males and 1 million females born on or after 1960 who were eligible for lung cancer screening on the basis of their smoking history according to the 2014 US Preventive Services Task Force recommendations. Modeled persons between the ages of 55 and 80 years were screened from the age by which they had accumulated a 30-pack-per-year smoking history, and the screening stopped either after the age of 80 years or 15 years after they had stopped smoking, whichever occurred earlier.

Information on lung cancer risk, treatment costs, and outcomes as well as smoking cessation costs and outcomes was taken from Medicare data, national cancer registries, and published studies. The cessation intervention costs were derived by microcosting of the published components of each intervention combined with expert analysis. Researchers assumed that the cessation interventions would be offered to current smokers at their first screening according to 2014 US Preventive Services Task Force guidelines. The interventions that were modeled included pharmacotherapy only as well as pharmacotherapy with a variety of web-based and in-person individual and group counseling tools. The model estimated subjects' annual probability of developing lung cancer based on their ages, genders, and history of smoking, and it simulated lung cancer histology, stage, and cause-specific survival. Outcomes of the model for each of the cessation interventions included lung cancer cases and deaths, life-years saved (LYS), quality-adjusted life-years saved (QALY), costs, and cost-effectiveness.

Study Results

According to the JNCI article, “Cessation plus screening resulted in 21-28 fewer lung cancer cases and more LYS and QALYs per 100,000 screen eligible individuals, with only small differences between cessation strategies. Also, when limiting the population of interest to current smokers, individual counseling, and screening—vs. screening only—gained 9449 QALYs per 100,000 compared to 1001 QALYs per 100,000 overall screen-eligible population; similar results were seen for other interventions.”

Specifically, the researchers found that compared with screening by itself, all cessation interventions decreased cases of and deaths from lung cancer. The incremental cost-effectiveness of cessation strategies (relative to screening alone) included the following:
  • Pharmacotherapy at $555 per QALY.
  • Telephone counseling at $7562 per QALY.
  • Individual/personal counseling at $35,531 per QALY.

Dr. Meza notes that these cessation strategies have costs per QALY below acceptable cost thresholds and were more cost-effective in modeled cohorts of those who smoked the most. “One other important finding,” says Dr. Meza, “is that while there are differences between the approaches studied, these were small, suggesting that the choice of a specific cessation intervention to be implemented should be guided by practical concerns such as staff training and availability.”

Dr. Meza adds that one caveat is that researchers used data from cessation programs not specific to the lung screening setting to inform their modeling. “Currently, the NCI Smoking Cessation at Lung Examination Collaboration (SCALE) is conducting several randomized controlled trials of cessation interventions at the point of screening. Once these are finished, we'll be able to update our modeling and analyses with more specific and current data.”

Study Implications

“This study does break new ground because it developed a model to predict benefits in QALYs if various types of evidence-based cessation interventions were offered in the lung cancer screening setting,” says J. Lee Westmaas, PhD, scientific director of behavioral research at the American Cancer Society in Atlanta, Georgia.

Dr. Westmaas says that although previous studies have examined whether offering a cessation intervention together with lung cancer screening can increase cessation in comparison with not offering an intervention, this study's outcomes include QALYs and cost-effectiveness (among others), and it uses large amounts of data from various sources in its simulation model. “This is why I think this is a very important study,” he says.

Dr. Westmaas adds that he believes one takeaway from the study is that any evidence-based cessation intervention should be offered with lung cancer screening. “Many clinicians and cancer researchers are not even aware that there are effective interventions for cessation (according to research we've conducted), so making it clear to clinicians that just referring a patient to quitline counseling (using the 1-800-QUIT-NOW portal), which is easy enough to remember, can increase QALYs. Patient preferences should be taken into account, of course, because while some people may be fine with talking to a quitline counselor, others may prefer less interpersonal approaches, like pharmacotherapy, an online intervention, or a smartphone app or texting program for cessation.”

Dr. Westmaas says that following up on patients regarding their smoking status or quit attempt is also important, whether it be by email, a call, or a text notification. “We need to do a better job educating clinicians about the benefits of recommending cessation and providing options to patients who smoke.”

Staff training and availability to provide cessation assistance are important considerations as well, says Dr. Westmaas. “But for practices that may feel they don't have the resources to provide cessation assistance directly, referrals to cessation programs are still important. Automating such referrals if a patient is flagged in the practice's electronic health record would be an easy way to do that. Suggesting pharmacotherapy such as nicotine replacement therapy, even if patients were not thinking of quitting, should be routine.”
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