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Original Research |

Cost-Effectiveness of the Children's Oncology Group Long-Term Follow-up Screening Guidelines for Childhood Cancer Survivors at Risk for Treatment-Related Heart FailureCost-Effectiveness of Children's Oncology Group Echocardiographic Screening Guidelines

F. Lennie Wong, PhD; Smita Bhatia, MD, MPH; Wendy Landier, PhD, RN; Liton Francisco, BS; Wendy Leisenring, ScD; Melissa M. Hudson, MD; Gregory T. Armstrong, MD; Ann Mertens, PhD; Marilyn Stovall, PhD; Leslie L. Robison, PhD; Gary H. Lyman, MD, MPH; Steven E. Lipshultz, MD; and Saro H. Armenian, DO, MPH
[+] Article and Author Information

From City of Hope, Duarte, California; Fred Hutchinson Cancer Research Center, Seattle, Washington; St. Jude Children's Research Hospital, Memphis, Tennessee; Emory University School of Medicine, Atlanta, Georgia; University of Texas MD Anderson Cancer Center, Houston, Texas; and Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, Michigan.

Presented in abstract form at the annual meeting of the American Society of Clinical Oncology, Chicago, Illinois, 1–6 June 2012, and the 12th International Conference on Long-term Complications of Treatment of Children and Adolescents for Cancer, Williamsburg, Virginia, 8–9 June 2012.

Grant Support: In part by the Lance Armstrong Foundation (Drs. Wong and Armenian) and grants U24-CA55727 (Dr. Robison), U10-CA098543 (primary investigator Dr. Adamson), and 2 K12-CA001727-14 (primary investigator Dr. Mortimer) from the National Cancer Institute.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2498.

Reproducible Research Statement: Study protocol, statistical code, and data set: Not available.

Requests for Single Reprints: F. Lennie Wong, PhD, City of Hope, 1500 East Duarte Road, Duarte, CA 91010; e-mail, lwong@coh.org.

Current Author Addresses: Drs. Wong, Bhatia, Landier, Francisco, and Armenian: Department of Population Sciences, City of Hope, 1500 East Duarte Road, Duarte, CA 91010-3000.

Dr. Leisenring: Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, D5-360, PO Box 19024, Seattle, WA 98109.

Drs. Hudson, Armstrong, and Robison: Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 735, Memphis, TN 38105-3678.

Dr. Mertens: Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive NE, Atlanta, GA 30322.

Dr. Stovall: Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030.

Dr. Lyman: Hutchinson Institute for Cancer Outcome Research, University of Washington Schools of Public Health and Pharmacy, 1100 Fairview Avenue North, M3-B232, PO Box 19024, Seattle, WA 98109-1024.

Dr. Lipshultz: Department of Pediatrics, Wayne State University School of Medicine, 3901 Beaubien Boulevard, 1K40, Detroit, MI 48201-2196.

Author Contributions: Analysis and interpretation of the data: F.L. Wong, S. Bhatia, M.M. Hudson, G.T. Armstrong, A. Mertens, M. Stovall, G.H. Lyman, S.E. Lipshultz, S.H. Armenian.

Drafting of the article: F.L. Wong, S. Bhatia, W. Landier, W. Leisenring, M.M. Hudson, G.H. Lyman, S.E. Lipshultz, S.H. Armenian.

Critical revision of the article for important intellectual content: F.L. Wong, S. Bhatia, W. Landier, L. Francisco, W. Leisenring, M.M. Hudson, G.T. Armstrong, M. Stovall, L.L. Robison, G.H. Lyman, S.E. Lipshultz, S.H. Armenian.

Final approval of the article: F.L. Wong, S. Bhatia, W. Landier, L. Francisco, W. Leisenring, M.M. Hudson, G.T. Armstrong, A. Mertens, M. Stovall, L.L. Robison, G.H. Lyman, S.E. Lipshultz, S.H. Armenian.

Provision of study materials or patients: F.L. Wong, L. Francisco, W. Leisenring, M.M. Hudson, G.T. Armstrong, M. Stovall, L.L. Robison, S.H. Armenian.

Statistical expertise: F.L. Wong, W. Leisenring, G.H. Lyman.

Obtaining of funding: F.L. Wong, G.T. Armstrong, L.L. Robison, S.H. Armenian.

Administrative, technical, or logistic support: S. Bhatia, L. Francisco, M. Stovall, S.H. Armenian.

Collection and assembly of data: F.L. Wong, S. Bhatia, L. Francisco, G.T. Armstrong, A. Mertens, L.L. Robison, S.E. Lipshultz, S.H. Armenian.


Ann Intern Med. 2014;160(10):672-683. doi:10.7326/M13-2498
Text Size: A A A

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 β-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 β-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.

Figures

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Appendix Figure 1.

Four–health state transition diagram.

ALVD = asymptomatic left ventricular dysfunction; HF = heart failure.

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Appendix Figure 2.

Annual incidence of HF, by years since cancer diagnosis, for age at cancer diagnosis younger than 5 y.

HF = heart failure.

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Appendix Figure 3.

Annual incidence of HF, by years since cancer diagnosis, for age at cancer diagnosis 5 y or older.

HF = heart failure.

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Appendix Figure 4.

Annual non-HF mortality, by attained age.

HF = heart failure; RR = relative risk (compared with the U.S. population).

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Figure.

Tornado diagrams of the 1-way sensitivity analyses for ICER and the percentage reduction in the cumulative incidence of HF at 30 y after cancer diagnosis, by varying key variables.

HF = heart failure; ICER = incremental cost-effectiveness ratio; QALY = quality-adjusted life-year.

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Appendix Figure 5.

Two-way sensitivity analyses for ICERs, by varying the efficacy of ALVD treatment and the sensitivity and specificity of echocardiography for detecting ALVD.

ALVD = asymptomatic left ventricular dysfunction; ICER = incremental cost-effectiveness ratio; QALY = quality-adjusted life-year.

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