• Tufts Medical Center, Boston, Massachusetts (V.K., J.T.C., J.B.W., P.J.N., D.M.K.).
• Tufts Medical Center, Boston, Massachusetts, and Leiden University Medical Center, Leiden, the Netherlands (D.v.).
• Harvard School of Public Health, Boston, Massachusetts (D.I.S.).

BACKGROUND: Targeting low-dose computed tomography (LDCT) for lung cancer screening to persons at highest risk for lung cancer mortality has been suggested to improve screening efficiency.

OBJECTIVE: To quantify the value of risk-targeted selection for lung cancer screening compared with National Lung Screening Trial (NLST) eligibility criteria.

DESIGN: Cost-effectiveness analysis using a multistate prediction model.

DATA SOURCES: NLST.

TARGET POPULATION: Current and former smokers eligible for lung cancer screening.

TIME HORIZON: Lifetime.

PERSPECTIVE: Health care sector.

INTERVENTION: Risk-targeted versus NLST-based screening.

OUTCOME MEASURES: Incremental 7-year mortality, life expectancy, quality-adjusted life-years (QALYs), costs, and cost-effectiveness of screening with LDCT versus chest radiography at each decile of lung cancer mortality risk.

RESULTS OF BASE-CASE ANALYSIS: Participants at greater risk for lung cancer mortality were older and had more comorbid conditions and higher screening-related costs. The incremental lung cancer mortality benefits during the first 7 years ranged from 1.2 to 9.5 lung cancer deaths prevented per 10 000 person-years for the lowest to highest risk deciles, respectively (extreme decile ratio, 7.9). The gradient of benefits across risk groups, however, was attenuated in terms of life-years (extreme decile ratio, 3.6) and QALYs (extreme decile ratio, 2.4). The incremental cost-effectiveness ratios (ICERs) were similar across risk deciles ($75 000 per QALY in the lowest risk decile to $53 000 per QALY in the highest risk decile). Payers willing to pay $100 000 per QALY would pay for LDCT screening for all decile groups.

RESULTS OF SENSITIVITY ANALYSIS: Alternative assumptions did not substantially alter our findings.

LIMITATION: Our model did not account for all correlated differences between lung cancer mortality risk and quality of life.

CONCLUSIONS: Although risk targeting may improve screening efficiency in terms of early lung cancer mortality per person screened, the gains in efficiency are attenuated and modest in terms of life-years, QALYs, and cost-effectiveness.

PRIMARY FUNDING SOURCE: National Institutes of Health (U01NS086294).