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.”

Photo credit: Shutterstock/Mike_shots

中文翻译：

---

将戒烟与肺癌筛查相结合可以挽救生命

关键点

• 肺癌筛查时的戒烟干预具有成本效益。
• 本研究中考虑的所有戒烟方法在以相似成本提供益处方面大致相同。

一项新的研究发现，在肺癌筛查的同时为当前吸烟者提供戒烟干预措施比单独筛查可以提供更多年的挽救生命的好处，而且增加的费用很少。该研究发表在《美国国家癌症研究所杂志》（JNCI；2021 年 1 月 23 日在线发表。doi:10.1093/jnci/djab002）。

医疗保险和医疗补助服务中心以及包括美国癌症协会在内的国家卫生组织的指南建议，应在肺癌筛查的同时提供戒烟方法。然而，在当前的肺筛查临床实践中，戒烟干预通常被忽略，部分原因是它们的增量效益和成本效益不确定。

在由许多相同作者撰写并几乎同时发表在《胸部肿瘤学杂志》 (2020;15:1160-1169.doi:10.1016/j.jtho.2020.02.008) 上的相关文章中，研究人员指出大约 50% 符合筛查条件的人目前是吸烟者，他们估计，联合使用筛查和戒烟干预以及 10% 的戒烟率可能比单独筛查多预防 14% 的肺癌死亡。目前的JNCI研究扩展了该研究，以估计在肺癌筛查中添加戒烟干预措施的成本效益。

JNCI研究的高级研究作者、密歇根州安娜堡密歇根大学流行病学系副教授Rafael Meza 博士说：“我们的分析 [在JNCI研究中]，包括不同方法之间的比较，表明肺癌筛查中的戒烟计划以合理的成本极大地扩大了肺癌的益处，使其更具成本效益。”

学习详情

在JNCI研究中，研究人员使用癌症干预和监测建模网络模拟模型作为基础，估计肺癌筛查时 5 种常见戒烟干预措施的收益、成本和成本效益。该模型的输入包括 1960 年或之后出生的 100 万男性和 100 万女性，根据 2014 年美国预防服务工作组的建议，他们有资格根据吸烟史进行肺癌筛查。年龄在 55 至 80 岁之间的建模人群从他们每年累积 30 包吸烟史的年龄开始进行筛查，并且在 80 岁或戒烟 15 年后停止筛查，以较早发生者为准。

有关肺癌风险、治疗成本和结果以及戒烟成本和结果的信息来自医疗保险数据、国家癌症登记处和已发表的研究。戒烟干预成本是通过对每种干预措施的已发表组成部分进行微观成本计算并结合专家分析得出的。研究人员假设根据 2014 年美国预防服务工作组指南，将在当前吸烟者的第一次筛查中提供戒烟干预措施。建模的干预措施仅包括药物疗法以及具有各种基于网络和面对面的个人和团体咨询工具的药物疗法。该模型根据受试者的年龄、性别和吸烟史估计了受试者每年患肺癌的概率，并模拟了肺癌的组织学，阶段和特定原因的生存。每种戒烟干预措施的模型结果包括肺癌病例和死亡、节省的生命年 (LYS)、质量调整的节省的生命年 (QALY)、成本和成本效益。

研究结果

根据JNCI的文章，“戒烟加筛查导致每 100,000 名符合筛查条件的个体中肺癌病例减少 21-28 例，而 LYS 和 QALYs 增加，而戒烟策略之间的差异很小。此外，当将感兴趣的人群限制在当前吸烟者、个人咨询和筛查时——与非吸烟者相比。仅筛查——每 100,000 人获得 9449 QALY，而每 100,000 名符合筛查条件的总人口获得 1001 QALY；其他干预措施也看到了类似的结果。”

具体来说，研究人员发现，与筛查本身相比，所有戒烟干预措施都减少了肺癌的病例和死亡人数。戒烟策略的增量成本效益（相对于单独的筛查）包括以下内容：

• 每 QALY 555 美元的药物治疗。
• 每个 QALY 7562 美元的电话咨询。
• 个人/个人咨询，每个 QALY 35,531 美元。

Meza 博士指出，这些戒烟策略的每个 QALY 成本低于可接受的成本阈值，并且在吸烟最多的人群中更具成本效益。“另一个重要发现，”Meza 博士说，“虽然所研究的方法之间存在差异，但差异很小，这表明要实施的特定戒烟干预措施的选择应以员工培训等实际问题为指导。和可用性。”

Meza 博士补充说，一个警告是研究人员使用了来自戒烟计划的数据，而不是特定于肺部筛查设置的数据来为他们的模型提供信息。“目前，NCI 戒烟合作组织 (SCALE) 正在开展几项筛查时戒烟干预的随机对照试验。一旦这些完成，我们将能够使用更具体和最新的数据更新我们的建模和分析。”

研究意义

“这项研究确实开辟了新天地，因为它开发了一个模型来预测如果在肺癌筛查环境中提供各种类型的基于证据的戒烟干预措施，则 QALYs 的益处，”J. Lee Westmaas 博士说，他是行为研究科学主任。佐治亚州亚特兰大的美国癌症协会。

Westmaas 博士说，虽然之前的研究已经检验了与不提供干预相比，提供戒烟干预和肺癌筛查是否可以增加戒烟，但这项研究的结果包括 QALY 和成本效益（以及其他），并且它使用了大量在其模拟模型中收集来自各种来源的数据。“这就是为什么我认为这是一项非常重要的研究，”他说。

Westmaas 博士补充说，他认为这项研究的一个收获是，任何基于证据的戒烟干预都应该与肺癌筛查一起提供。“许多临床医生和癌症研究人员甚至不知道有有效的戒烟干预措施（根据我们进行的研究），因此向临床医生明确表示只是将患者转介到戒烟热线咨询（使用 1-800-QUIT- NOW 门户），它很容易记住，可以增加 QALY。当然，应该考虑患者的偏好，因为虽然有些人可能会接受与戒烟热线辅导员交谈，但其他人可能更喜欢较少人际交往的方法，例如药物疗法、在线干预或智能手机应用程序或短信程序来戒烟。”

Westmaas 博士说，跟踪患者的吸烟状况或戒烟尝试也很重要，无论是通过电子邮件、电话还是短信通知。“我们需要更好地教育临床医生，让他们了解建议戒烟的好处，并为吸烟的患者提供选择。”

Westmaas 博士说，员工培训和提供戒烟帮助的可用性也是重要的考虑因素。“但对于那些可能觉得自己没有资源直接提供戒烟帮助的做法，转介戒烟计划仍然很重要。如果患者在诊所的电子健康记录中被标记，则自动进行此类转诊将是一种简单的方法。建议诸如尼古丁替代疗法之类的药物疗法，即使患者不考虑戒烟，也应该成为常规。”

图片来源：Shutterstock/Mike_shots