Cost-effectiveness of the children's oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure

F. Lennie Wong, Smita Bhatia, Wendy Landier, Liton Francisco, Wendy Leisenring, Melissa M. Hudson, Gregory T. Armstrong, Ann Mertens, Marilyn Stovall, Leslie L. Robison, Gary H. Lyman, Steven E. Lipshultz, Saro H. Armenian

Research output: Contribution to journalArticlepeer-review

74 Scopus citations


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 angiotensinconverting 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 -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 costeffective than the COG guidelines. Primary Funding Source: Lance Armstrong Foundation and National Cancer Institute.

Original languageEnglish (US)
Pages (from-to)672-683
Number of pages12
JournalAnnals of internal medicine
Issue number10
StatePublished - May 20 2014
Externally publishedYes

ASJC Scopus subject areas

  • Internal Medicine


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