Applying NICE's Disease Severity Modifier to the Context of Cancer Screening

OBJECTIVES: The National Institute for Heath and Care Excellence (NICE) considers disease severity in technology appraisals by modifying quality adjusted life years (QALY) gained for diseases where absolute (≥12 QALYs lost with the condition vs those without) or proportional QALY (≥85% of remaining QALYs) shortfall criteria are met. This modification has not previously been applied to cancer screening. Focusing on the condition of undiagnosed lung cancer, we quantify the population for which the severity modifier would apply.

METHODS: We estimated the prevalence of undiagnosed lung cancer by age (50-79) and stage (I-IV) using an interception approach, considering English lung cancer incidence rates and stage-specific dwell times. Expected QALYs for an undiagnosed lung cancer were calculated by applying age-specific utility to the estimated lead time to cancer diagnosis, and stage-specific cancer utility to the England-specific estimated mean survival for the stage at which the cancer would be diagnosed. The absolute and proportional QALY shortfalls for each age and stage were then compared to NICE's severity criteria.

RESULTS: The age range over which the QALY shortfall met the severity criteria broadened by the stage of undiagnosed cancer. Neither criterion was met for undiagnosed stage I lung at any age. For undiagnosed stage II lung cancer, the absolute criterion was met at ages 50-51. For undiagnosed stage III cancer the absolute and proportional criteria were met at ages 50-57 and 50-70, respectively. The absolute QALY shortfall criterion was met at ages 50-60 for undiagnosed stage IV lung cancer, whereas the proportional shortfall was met at all ages. Overall, 41% of undiagnosed cancers in a population without lung cancer screening met severity criteria.

CONCLUSIONS: A significant fraction of those with undiagnosed lung cancer have QALY shortfalls meeting severity modifier criteria, suggesting the disease severity modifier may be relevant in economic evaluations of lung, and potentially other, cancer screening.