US population-level costs and cost-savings associated with long-term follow-up (LTFU) screening for survivors of childhood cancer.

Abstract

10059 Background: Children’s Oncology Group’s (COG) LTFU Guideline adherence is poor. We evaluated the impact of universal payer coverage on patient costs associated with adherence to COG-directed cardiomyopathy (CM), breast (BC), and colorectal cancer (CRC) screening. Methods: We reviewed coverage guidelines for Medicare, Medicaid, and commercial plans for COG screening for exposure-based CM (echocardiogram [echo] every 2-5 yrs based on cumulative chest radiation (RT) and anthracyclines), BC (yearly mammography [MAM] and magnetic resonance imaging [MRI] beginning at age 25 or 8 yrs from chest RT), and CRC (colonoscopy [COL] every 5 yrs or multitarget stool DNA [MTSD] every 3 yrs, starting 5 yrs from abdominopelvic RT or age 30). The eligible US population was estimated from SEER and American Cancer Society cancer survival rates. Cost of screening was derived from the Center for Medicare & Medicaid Services (CMS) and of lifetime treatment from published data. Net costs vs. benefits (in US $) were calculated, assuming 100% adherence, as the sum of cost-savings (i.e., treatment costs averted) and monetary value of quality-adjusted life-yrs (QALYs) gained minus costs (e.g., screening, false positives). Results: Screening coverage varied by payer (Table). BC screening for all US survivors with prior chest RT (n = 42,847) yielded a net benefit ranging from $0.5 to $3.4 billion, with patients paying 19.3% of costs. Among 138,702 survivors at-risk of CRC, net benefit from COL and MTSD was $5.7 and 5.0 billion. Patients nationally bore 0% of MTSD but 60% of COL costs. Among 218,322 at-risk of CM, costs exceeded cost-savings by $1.7 billion when using the median echo cost by payer but yielded a $400 million benefit when using the average cost of CMS and the lowest commercial plan. Patients bore 90% of CM costs. Conclusions: Screening for CM, BC, and CRC per the COG guidelines results in substantial cost savings and benefits. However, as adherence is < 100% due to copay, inadequate coverage, and low provider awareness, interventions and policies focused on boosting adherence could yield cost savings to the health system and reduce disease burden in this population. COG Screening By Payer (Subset) Cost Bearer, % (Aggregated across Payers) Value of Cases Averted Value of QALYs Gained Total Cost Net Costs (-) or Benefit (+) Medicare Medicaid Commercial Patient (Pt) Payer Billion US $, Range BCMAM & MRI Coverage Full, at physician’s discretion MAM: Full MRI: None Full 19.3 80.7 NA* 2.6 - 5.9 2.1 - 2.5 0.5 - 3.4 Pt Cost 20% copay after Part B deductible 20% copay MAM: 0% MRI: 15-30% copay after deductible CRCCOL or MTSD Coverage COL: None MTSD: Full NoneFull NoneFull COL: 60 40 3.7 4.4 2.4 5.7 Pt Cost COL: 100% MTSD: 0% 100% 0% 100% 0% MTSD: 0 100 2.9 4.0 1.9 5.0 CMEcho Coverage None None ≤2 covered after age 18 90.3 9.7 0.01 0.74 0.36 - 2.5 -1.7 - 0.4 Pt Cost 100% 100% 15%-30% copay after deductible *Not available in published models.