Abstract
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.