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Glenn M. Chertow, MD, MPH; A. David Paltiel, PhD; William F. Owen, Jr, MD; J. Michael Lazarus, MD

Arch Intern Med. 1996;156(12):1345-1350.

Abstract
Background
Limited evidence suggests that persons with end-stage renal disease (ESRD) may be at increased risk for malignancy. The appropriateness of screening procedures in this population has not been evaluated.

Objective
To determine the relative cost-effectiveness of hypothetical cancer screening programs in the population with ESRD compared with the general population.

Methods
We performed a cost-effectiveness analysis, employing the declining exponential approximation of life expectancy. Assumptions were put forth to bias the model in favor of cancer screening. Secondary comparisons were made between cancer screening and other interventions targeted to patients with ESRD.

Results
The costs per unit of survival benefit conferred by cancer screening were 1.6 to 19.3 times greater among patients with ESRD than in the general population, depending on age, sex, and race, and assumptions outlined herein. For persons with ESRD, the net gain in life expectancy from a typical cancer screening program was calculated to be 5 days or less. Similar survival gains could be obtained via a reduction of 0.02% or less in the baseline ESRD-related mortality rate.

Conclusions
These analyses suggest that routine cancer screening in the population with ESRD is a relatively inefficient allocation of financial resources. Direction of funds toward improving the quality of dialysis could attain such an objective at substantially lower cost. Furthermore, these findings highlight the importance of competing risks as a consideration in the evaluation of screening strategies and other interventions targeted to patients with ESRD and to other populations with chronic diseases associated with reduced survival.

(Arch Intern Med. 1996;156:1345-1350)

Author Affiliations
From the Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School (Drs Chertow, Owen, and Lazarus), and Department of Health Policy and Management, Harvard School of Public Health (Dr Paltiel), Boston, Mass.

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