Routine Echocardiography Screening for Asymptomatic Left Ventricular Dysfunction in Childhood Cancer Survivors: A Model-Based Estimation of the Clinical and Economic Effects

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Abstract

Background:

Childhood cancer survivors treated with cardiotoxic therapies are recommended to have routine cardiac assessment every 1 to 5 years, but the long-term benefits are uncertain.

Objective:

To estimate the cost-effectiveness of routine cardiac assessment to detect asymptomatic left ventricular dysfunction and of angiotensin-converting enzyme inhibitor and β-blocker treatment to reduce congestive heart failure (CHF) incidence in childhood cancer survivors.

Design:

Simulation model.

Data Sources:

Literature, including data from the Childhood Cancer Survivor Study.

Target Population:

Childhood cancer survivors.

Time Horizon:

Lifetime.

Perspective:

Societal.

Intervention:

Interval-based echocardiography assessment every 1, 2, 5, or 10 years, with subsequent angiotensin-converting enzyme inhibitor or β-blocker treatment for patients with positive test results.

Outcome Measures:

Lifetime risk for systolic CHF, lifetime costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios (ICERs).

Results of Base-Case Analysis:

The lifetime risk for systolic CHF among 5-year childhood cancer survivors aged 15 years was 18.8% without routine cardiac assessment (average age at onset, 58.8 years). Routine echocardiography reduced lifetime risk for CHF by 2.3% (with assessment every 10 years) to 8.7% (annual assessment). The ICER for assessment every 10 years was $111 600 per quality-adjusted life-year (QALY) compared with no assessment. Assessment every 5 years had an ICER of $117 900 per QALY, and ICERs for more frequent assessment exceeded $165 000 per QALY.

Results of Sensitivity Analysis:

Results were sensitive to treatment effectiveness, absolute excess risk for CHF, and asymptomatic left ventricular dysfunction asymptomatic period. The probability that assessment every 10 or 5 years was preferred at a $100 000-per-QALY threshold was 0.33 for the overall cohort.

Limitation:

Treatment effectiveness was based on adult data.

Conclusion:

Current recommendations for cardiac assessment may reduce CHF incidence, but less frequent assessment may be preferable.

Primary Funding Source:

National Cancer Institute.

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