Problema de Salud AUGE N°81
Cáncer de pulmón en persona de 15 años y más
Recomendación – Dg1 / Juicio del Panel y Evidencia
Dg.1.En personas mayores a 50 años fumadores o exfumadores, el Ministerio de Salud SUGIERE NO realizar tamizaje con tomografía computarizada de tórax de baja dosis.
Comentarios del Panel de Expertos:
►La decisión de realizar o no tamizaje con tomografía computarizada de tórax de baja dosis debe individualizarse a las circunstancias clínicas y valores y preferencias de cada paciente. Personas con alto riesgo de cáncer de pulmón (por ejemplo, antecedentes familiares de cáncer) pudieran beneficiarse del tamizaje. En este caso, el panel considera que la tomografía computarizada ofrece mejor rendimiento diagnóstico que la radiografía de tórax, y por lo tanto resulta más útil para tomar decisiones respecto del tratamiento y seguimiento.
►El panel además señala que el tamizaje puede aprovecharse para promover medidas de cesación del tabaquismo.
El panel de expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.
A continuación se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
| Triviales | Pequeños | Moderados | Grandes | Varía | No lo sé |
|---|
Triviales: El panel de expertos de la Guía estimó que los efectos deseables de «realizar tamizaje con tomografía computarizada de tórax de baja dosis» en comparación a «no realizar» son triviales o no relevantes, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.
Además, a solicitud del panel, se evaluó si las potenciales conclusiones que se desprendían de la Tabla de Resumen de Resultados se modificaban al incorporar los ensayos aleatorizados NLST (2010) [27] y LSS (2005) [31] que comparan “tomografía computarizada de tórax sin contraste de baja dosis” con “radiografía de tórax”. Al realizar el ejercicio, su incorporación no cambiaba las conclusiones, arrojando un RR: 1,05 (IC95%: 0,84 a 1,30) y un I2 82%, por lo que se decidió no incorporarlos a la tabla.
Finalmente el panel indica que el desenlace «calidad de vida» sería un desenlace relevante de evaluar pero no se identificó en la literatura.
Evidencia de investigación
|
Tamizaje con tomografía computarizada de tórax sin contraste de baja dosis en persona con índice paquete año (IPA) ≥ 20 |
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|
Pacientes |
Personas mayores a 50 años con índice paquete año (IPA) ≥ 20. |
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|
Intervención |
Tamizaje con tomografía computarizada de tórax sin contraste de baja dosis. |
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|
Comparación |
No tamizaje. |
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|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
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|
No tamizaje |
Tamizaje con tomografía de baja dosis |
Diferencia (IC 95%) |
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|
Mortalidad |
RR 1,20 (0,77 a 1,85) — 3 ensayos / 61.707 pacientes [26, 32, 34] |
17 por 1000 |
20 por 1000 |
Diferencia: 3 más por 1000 (5 menos a 19 más) |
⊕⊕◯◯1,2,3 Baja |
El uso de tamizaje con tomografía computarizada de tórax sin contraste de baja dosis, podría aumentar la mortalidad en cáncer de pulmón. Sin embargo, el efecto podría ser demasiado pequeño para ser considerado importante por los pacientes. |
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo SIN tomografía computarizada de baja dosis está basado en el riesgo del grupo control en los estudios. El riesgo CON tomografía computarizada de baja dosis (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 A pesar que la evidencia identificada proviene de una población que no es directamente la abordada por la pregunta de este informe (no proviene exclusivamente de mayores de 50 años con IPA ≥ 20), se decidió no disminuir la certeza de evidencia por este factor, ya que la mayoría de los pacientes incluidos en los diferentes ensayos eran fumadores activos.
2 Se disminuyó un nivel de certeza por imprecisión, ya que el intervalo de confianza incluye la posibilidad de beneficio, sin embargo, éste podría ser de baja magnitud.
3 Se disminuyó un nivel de certeza por inconsistencia entre los resultados (I2 87%).
Fecha de elaboración de la tabla: Agosto, 2018
Referencias
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
| Grandes | Moderados | Pequeños | Triviales | Varía | No lo sé |
|---|
Triviales: El panel de expertos de la Guía estimó que los efectos indeseables de «realizar tamizaje con tomografía computarizada de tórax de baja dosis» en comparación a «no realizar» son triviales o no relevantes, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.
Además, a solicitud del panel, se evaluó si las potenciales conclusiones que se desprendían de la Tabla de Resumen de Resultados se modificaban al incorporar los ensayos aleatorizados NLST (2010) [27] y LSS (2005) [31] que comparan “tomografía computarizada de tórax sin contraste de baja dosis” con “radiografía de tórax”. Al realizar el ejercicio, su incorporación no cambiaba las conclusiones, arrojando un RR: 1,05 (IC95%: 0,84 a 1,30) y un I2 82%, por lo que se decidió no incorporarlos a la tabla.
Evidencia de investigación
|
Tamizaje con tomografía computarizada de tórax sin contraste de baja dosis en persona con índice paquete año (IPA) ≥ 20 |
||||||
|
Pacientes |
Personas mayores a 50 años con índice paquete año (IPA) ≥ 20. |
|||||
|
Intervención |
Tamizaje con tomografía computarizada de tórax sin contraste de baja dosis. |
|||||
|
Comparación |
No tamizaje. |
|||||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
||
|
No tamizaje |
Tamizaje con tomografía de baja dosis |
Diferencia (IC 95%) |
||||
|
Mortalidad |
RR 1,20 (0,77 a 1,85) — 3 ensayos / 61.707 pacientes [26, 32, 34] |
17 por 1000 |
20 por 1000 |
Diferencia: 3 más por 1000 (5 menos a 19 más) |
⊕⊕◯◯1,2,3 Baja |
El uso de tamizaje con tomografía computarizada de tórax sin contraste de baja dosis, podría aumentar la mortalidad en cáncer de pulmón. Sin embargo, el efecto podría ser demasiado pequeño para ser considerado importante por los pacientes. |
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo SIN tomografía computarizada de baja dosis está basado en el riesgo del grupo control en los estudios. El riesgo CON tomografía computarizada de baja dosis (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 A pesar que la evidencia identificada proviene de una población que no es directamente la abordada por la pregunta de este informe (no proviene exclusivamente de mayores de 50 años con IPA ≥ 20), se decidió no disminuir la certeza de evidencia por este factor, ya que la mayoría de los pacientes incluidos en los diferentes ensayos eran fumadores activos.
2 Se disminuyó un nivel de certeza por imprecisión, ya que el intervalo de confianza incluye la posibilidad de beneficio, sin embargo, éste podría ser de baja magnitud.
3 Se disminuyó un nivel de certeza por inconsistencia entre los resultados (I2 87%).
Fecha de elaboración de la tabla: Agosto, 2018
Referencias
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62. Novello S, Fava C, Borasio P, Dogliotti L, Cortese G, Crida B, Selvaggi G, Lausi P, Brizzi MP, Sperone P, Cardinale L, Ferraris F, Perotto F, Priola A, Scagliotti GV. Three-year findings of an early lung cancer detection feasibility study with low-dose spiral computed tomography in heavy smokers. Annals of oncology : official journal of the European Society for Medical Oncology / ESMO. 2005;16(10):1662-6.
63. Sone S, Nakayama T, Honda T, Tsushima K, Li F, Haniuda M, Takahashi Y, Suzuki T, Yamanda T, Kondo R, Hanaoka T, Takayama F, Kubo K, Fushimi H. Long-term follow-up study of a population-based 1996-1998 mass screening programme for lung cancer using mobile low-dose spiral computed tomography. Lung cancer (Amsterdam, Netherlands). 2007;58(3):329-41.
64. Tsushima K, Sone S, Hanaoka T, Kubo K. Radiological diagnosis of small pulmonary nodules detected on low-dose screening computed tomography. Respirology (Carlton, Vic.). 2008;13(6):817-24.
65. Cox LS, Clark MM, Jett JR, Patten CA, Schroeder DR, Nirelli LM, Swensen SJ, Hurt RD. Change in smoking status after spiral chest computed tomography scan screening. Cancer. 2003;98(11):2495-501.
66. Schnoll RA, Miller SM, Unger M, McAleer C, Halbherr T, Bradley P. Characteristics of female smokers attending a lung cancer screening program: a pilot study with implications for program development. Lung cancer (Amsterdam, Netherlands). 2002;37(3):257-65.
67. Tiitola, Mia, Kivisaari, Leena, Huuskonen, Matti S., Mattson, Karin, Koskinen, Heikki, Lehtola, Hannu, Zitting, Anders, Vehmas, Tapio. Computed tomography screening for lung cancer in asbestos-exposed workers. Lung Cancer. 2002;35(1):17-22.
68. Miller A, Markowitz S, Manowitz A, Miller JA. Lung cancer screening using low-dose high-resolution CT scanning in a high-risk workforce: 3500 nuclear fuel workers in three US states. Chest. 2004;125(5 Suppl):152S-3S.
69. Roberts HC, Patsios DA, Paul NS, DePerrot M, Teel W, Bayanati H, Shepherd F, Johnston MR. Screening for malignant pleural mesothelioma and lung cancer in individuals with a history of asbestos exposure. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2009;4(5):620-8.
70. Mastrangelo G, Ballarin MN, Bellini E, Bizzotto R, Zannol F, Gioffrè F, Gobbi M, Tessadri G, Marchiori L, Marangi G, Bozzolan S, Lange JH, Valentini F, Spolaore P. Feasibility of a screening programme for lung cancer in former asbestos workers. Occupational medicine (Oxford, England). 2008;58(3):175-80.
71. Das M, Mühlenbruch G, Mahnken AH, Hering KG, Sirbu H, Zschiesche W, Knoll L, Felten MK, Kraus T, Günther RW, Wildberger JE. Asbestos Surveillance Program Aachen (ASPA): initial results from baseline screening for lung cancer in asbestos-exposed high-risk individuals using low-dose multidetector-row CT. European radiology. 2007;17(5):1193-9.
72. Vierikko T, Järvenpää R, Autti T, Oksa P, Huuskonen M, Kaleva S, Laurikka J, Kajander S, Paakkola K, Saarelainen S, Salomaa ER, Tossavainen A, Tukiainen P, Uitti J, Vehmas T. Chest CT screening of asbestos-exposed workers: lung lesions and incidental findings. The European respiratory journal. 2007;29(1):78-84.
73. Fasola G, Belvedere O, Aita M, Zanin T, Follador A, Cassetti P, Meduri S, De Pangher V, Pignata G, Rosolen V, Barbone F, Grossi F. Low-dose computed tomography screening for lung cancer and pleural mesothelioma in an asbestos-exposed population: baseline results of a prospective, nonrandomized feasibility trial–an Alpe-adria Thoracic Oncology Multidisciplinary Group Study (ATOM 002). The oncologist. 2007;12(10):1215-24.
74. Clin B, Morlais F, Guittet L, Gislard A, Marquignon MF, Paris C, Caillard JF, Launoy G, Letourneux M. Performance of chest radiograph and CT scan for lung cancer screening in asbestos-exposed workers. Occupational and environmental medicine. 2009;66(8):529-34.
75. Veronesi G, Maisonneuve P, Bellomi M, Rampinelli C, Durli I, Bertolotti R, Spaggiari L. Estimating overdiagnosis in low-dose computed tomography screening for lung cancer: a cohort study. Annals of internal medicine. 2012;157(11):776-784.
76. Fujikawa A, Takiguchi Y, Mizuno S, Uruma T, Suzuki K, Nagao K, Niijima M, Edo H, Hino M, Kuriyama T. Lung cancer screening–comparison of computed tomography and X-ray. Lung cancer (Amsterdam, Netherlands). 2008;61(2):195-201.
77. Bach PB, Jett JR, Pastorino U, Tockman MS, Swensen SJ, Begg CB. Computed tomography screening and lung cancer outcomes. JAMA. 2007;297(9):953-61.
78. Matsumoto M, Horikoshi H, Moteki T, Hatori N, Tateno Y, Iinuma T, Matsumoto T, Yamamoto S, Baba T. [A pilot study with lung-cancer screening CT (LSCT) at the secondary screening for lung cancer detection]. Nihon Igaku Hoshasen Gakkai zasshi. Nippon acta radiologica. 1995;55(3):172-9.
79. Vierikko T, Kivistö S, Järvenpää R, Uitti J, Oksa P, Virtema P, Vehmas T. Psychological impact of computed tomography screening for lung cancer and occupational pulmonary disease among asbestos-exposed workers. European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation (ECP). 2009;18(3):203-6.
80. Anderson CM, Yip R, Henschke CI, Yankelevitz DF, Ostroff JS, Burns DM. Smoking cessation and relapse during a lung cancer screening program. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2009;18(12):3476-83.
81. Shemesh J, Henschke CI, Farooqi A, Yip R, Yankelevitz DF, Shaham D, Miettinen OS. Frequency of coronary artery calcification on low-dose computed tomography screening for lung cancer. Clinical imaging. 2006;30(3):181-5.
82. Pastorino, U., Marchiano, A., Sverzellati, N. et al. A less intensive screening modality, such as CT every 2 years instead of annual CT, is not harmful for heavy smokers. JOURNAL OF THORACIC ONCOLOGY. 2011;6.
83. Beinfeld MT, Wittenberg E, Gazelle GS. Cost-effectiveness of whole-body CT screening. Radiology. 2005;234(2):415-22.
84. Chirikos TN, Hazelton T, Tockman M, Clark R. Cost-effectiveness of screening for lung cancer. JAMA. 2003;289(18):2358; author reply 2358-9.
85. Marshall D, Simpson KN, Earle CC, Chu C. Potential cost-effectiveness of one-time screening for lung cancer (LC) in a high risk cohort. Lung cancer (Amsterdam, Netherlands). 2001;32(3):227-36.
86. Pyenson BS, Sander MS, Jiang Y, Kahn H, Mulshine JL. An actuarial analysis shows that offering lung cancer screening as an insurance benefit would save lives at relatively low cost. Health affairs (Project Hope). 2012;31(4):770-9.
87. Pyenson BS, Henschke CI, Yankelevitz DF, Yip R, Dec E. Offering lung cancer screening to high-risk medicare beneficiaries saves lives and is cost-effective: an actuarial analysis. American health & drug benefits. 2014;7(5):272-82.
88. Mahadevia PJ, Fleisher LA, Frick KD, Eng J, Goodman SN, Powe NR. Lung cancer screening with helical computed tomography in older adult smokers: a decision and cost-effectiveness analysis. JAMA. 2003;289(3):313-22.
89. Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR, Naeim A, Church TR, Silvestri GA, Gorelick J, Gatsonis C, National Lung Screening Trial Research Team. Cost-effectiveness of CT screening in the National Lung Screening Trial. The New England journal of medicine. 2014;371(19):1793-802.
90. McMahon PM, Kong CY, Bouzan C, Weinstein MC, Cipriano LE, Tramontano AC, Johnson BE, Weeks JC, Gazelle GS. Cost-effectiveness of computed tomography screening for lung cancer in the United States. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2011;6(11):1841-8.
91. Okamoto N. Cost-effectiveness of lung cancer screening in Japan. Cancer. 2000;89(11 Suppl):2489-93.
92. Manser R, Dalton A, Carter R, Byrnes G, Elwood M, Campbell DA. Cost-effectiveness analysis of screening for lung cancer with low dose spiral CT (computed tomography) in the Australian setting. Lung cancer (Amsterdam, Netherlands). 2005;48(2):171-85.
93. Villanti AC, Jiang Y, Abrams DB, Pyenson BS. A cost-utility analysis of lung cancer screening and the additional benefits of incorporating smoking cessation interventions. PloS one. 2013;8(8):e71379.
94. Shmueli A, Fraifeld S, Peretz T, Gutfeld O, Gips M, Sosna J, Shaham D. Cost-effectiveness of baseline low-dose computed tomography screening for lung cancer: the Israeli experience. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research. 2013;16(6):922-31.
95. Marshall D, Simpson KN, Earle CC, Chu CW. Economic decision analysis model of screening for lung cancer. European journal of cancer (Oxford, England : 1990). 2001;37(14):1759-67.
96. Shaham D, Breuer R, Copel L, Agid R, Makori A, Kisselgoff D, Goitein O, Izhar U, Berkman N, Heching N, Sosna J, Bar-Ziv J, Libson E. Computed tomography screening for lung cancer: applicability of an international protocol in a single-institution environment. Clinical lung cancer. 2006;7(4):262-7.
97. ELCAP (Early Lung Cancer Action Project). Henschke CI, McCauley DI, Yankelevitz DF, Naidich DP, McGuinness G, Miettinen OS, Libby D, Pasmantier M, Koizumi J, Altorki N, Smith JP. Early lung cancer action project: a summary of the findings on baseline screening. The oncologist. 2001;6(2):147-52.
98. PLuSS (Pittsburgh Lung Screening Study). Byrne MM, Weissfeld J, Roberts MS. Anxiety, fear of cancer, and perceived risk of cancer following lung cancer screening. Medical decision making : an international journal of the Society for Medical Decision Making. 2008;28(6):917-25.
99. PALCAD (ProActive Lung Cancer Detection). MacRedmond R, McVey G, Lee M, Costello RW, Kenny D, Foley C, Logan PM. Screening for lung cancer using low dose CT scanning: results of 2 year follow up. Thorax. 2006;61(1):54-6.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Baja: Existe cierta incertidumbre respecto del efecto de «realizar tamizaje con tomografía computarizada de tórax de baja dosis» en comparación a «no realizar». La certeza general de la evidencia se centró en el desenlace en salud «mortalidad», dado que es considerado crítico y es el único reportado.
Evidencia de investigación
|
Desenlaces |
Importancia |
Certeza de la Evidencia |
|
Mortalidad |
CRÍTICO |
⨁⨁◯◯ |
a. Se disminuyó un nivel de certeza por inconsistencia entre los resultados (I2 87%).
b. Se decidió no disminuir por indirecto pese a no ser exclusivamente personas mayores a 50 años con índice paquete año (IPA) ≥ 20, ya que la mayoría de los pacientes incluidos en los diferentes ensayos eran fumadores activos.
c. Se disminuyó un nivel de certeza por imprecisión, ya que el intervalo de confianza incluye la posibilidad de efecto, sin embargo, éste podría ser de baja magnitud.
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Probablemente no hay incertidumbre ni variabilidad importantes: En función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud, el panel de expertos de la Guía consideró que probablemente no hay incertidumbre o ni variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «realizar tamizaje con tomografía computarizada de tórax de baja dosis» y «no realizar». En general, según la evidencia y la experiencia del panel, a las personas les interesa descartar si tienen cáncer de pulmón, es por ello que en su mayoría estaría dispuesto a realizarse un tamizaje. También existen personas que se realizan exámenes, como el TAC, para evaluar si mantienen el hábito tabáquico.
Evidencia de investigación
Se identificaron 7 estudio (1–7) que indagaron sobre la percepción que tenían personas fumadoras respecto a realizarse tomografía computarizada (TC) de baja dosis como cribado del cáncer de pulmón. Respecto a detección de cáncer de pulmón la mayoría no conocía las pruebas (1,2) y muy pocos conocía que permitía la detección temprana (1). Muchos participantes expresaron un fuerte deseo de realizarse exámenes de detección del cáncer de pulmón después que se les explicaba en qué consistía (1–3,5,6). Se identificaron las siguientes barreras para la detección del cáncer de pulmón:
• Costo del procedimiento, es muy costoso desde la perspectiva del paciente (1,2).
• Falta de trasporte, principalmente para los participantes de zonas rurales (2,4).
• Confusión en torno a resultados, es estresantes no tener claro los resultados, sobre todo cuando debes hacer más exámenes y cuando los médicos usan un lenguaje muy técnico (1,2).
• Creencias fatalistas, miedo a que confirmen el cáncer de pulmón y su consecuente asociación con la muerte(1,4,7). Además, existe la creencia de que los pulmones no son un órgano tratable parece ser una explicación común y socava el valor potencial de la detección(3).
• Desconfianza del sistema médico, creencia de que médicos y seguros indican pruebas/tratamiento con el objetivo de sacar provecho monetario(1).
• Falta de conocimiento, los participantes no conocía que estas pruebas permitían una detección temprana del cáncer de pulmón (1,5).
• Denegación al riesgo, ignorar el riesgo que implica fumar “muchos no fuman y tienen cáncer” (1).
• Miedo al procedimiento, en algunos el procedimiento TAC o resonancia magnética de por sí causan temor (no así la radiografía). Miedo a la exposición a radiación (1,7).
• Estigma social: La percepción de culpa y el estigma en torno al cáncer de pulmón como una enfermedad autoinfligida en los fumadores fueron implicados por los entrevistados como importantes elementos disuasivos sociales de la participación en el cribado(3).
Pacientes indicaron que la información más importante que se debe entregar para facilitar la toma de decisiones es: imágenes de un pulmón dañado por el cigarrillo, información general sobre el cáncer de pulmón, beneficios y daños de la tomografía computarizada de baja dosis, costo y duración del examen y posibles efectos futuros (2). Mostrar videos fue una medio efectivo para aumentar la aceptabilidad y conocimiento de realizarse un tomografía computarizada(5).
Referencias
2. Mishra SI, Sussman AL, Murrietta AM, Getrich CM, Rhyne R, Crowell RE, et al. Patient Perspectives on Low-Dose Computed Tomography for Lung Cancer Screening, New Mexico, 2014. Prev Chronic Dis [Internet]. 2016 [cited 2018 Aug 10];13:E108. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27536900
3. Quaife SL, Marlow LA V., McEwen A, Janes SM, Wardle J. Attitudes towards lung cancer screening in socioeconomically deprived and heavy smoking communities: informing screening communication. Heal Expect [Internet]. 2017 Aug [cited 2018 Aug 21];20(4):563–73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27397651
4. Patel D, Akporobaro A, Chinyanganya N, Hackshaw A, Seale C, Spiro SG, et al. Attitudes to participation in a lung cancer screening trial: a qualitative study. Thorax [Internet]. 2012 May [cited 2018 Aug 30];67(5):418–25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22106018
5. Volk RJ, Linder SK, Leal VB, Rabius V, Cinciripini PM, Kamath GR, et al. Feasibility of a patient decision aid about lung cancer screening with low-dose computed tomography. Prev Med (Baltim) [Internet]. 2014 May [cited 2018 Aug 30];62:60–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24518006
6. Kanodra NM, Pope C, Halbert CH, Silvestri GA, Rice LJ, Tanner NT. Primary Care Provider and Patient Perspectives on Lung Cancer Screening. A Qualitative Study. Ann Am Thorac Soc [Internet]. 2016 Nov [cited 2018 Aug 30];13(11):1977–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27676369
7. Jonnalagadda S, Bergamo C, Lin JJ, Lurslurchachai L, Diefenbach M, Smith C, et al. Beliefs and attitudes about lung cancer screening among smokers. Lung Cancer [Internet]. 2012 Sep [cited 2018 Aug 30];77(3):526–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22681870
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de valores y preferencias de los pacientes
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
No favorece la intervención ni la comparación: Considerando que la intervención es «realizar tamizaje con tomografía computarizada de tórax de baja dosis» y la comparación es «no realizar», el panel de expertos de la Guía opinó que la costo-efectividad no favorece ninguna de las dos alternativas., Aunque pacientes preferirían realizarse TAC, la evidencia presentada respecto a los desenlaces deseables e indeseables es imprecisa cuando se le compara con no realizar escáner, además el efecto indeseable del escáner de tórax podría ser demasiado pequeño para ser considerado importante por los pacientes.
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos moderados: El panel de expertos de la Guía consideró que los costos de «realizar tamizaje con tomografía computarizada de tórax de baja dosis» son moderados si se compara con los costos de «no realizar», en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
A continuación se muestran los costos referenciales, es preciso considerar que estos costos fueron recogidos con el único objetivo de constituir un antecedente aproximado.
El porcentaje de cobertura del seguro de salud sobre el precio de las prestaciones sanitarias, dependerá del tipo de seguro de cada paciente.
|
ítem |
Intervención: scanner de tórax sin contraste de baja dosis |
|
Tomografía Computarizada de Tórax. Incluye además: esternón, clavículas, articulación acromioclavicular, escapula, costillas, articulación esternoclavicular. Incluye todo el tórax o cada segmento o articulación. Incluye bilateralidad1 |
$ 120.780 |
|
|
$ 120.780 |
* Costos referenciales por cada vez.
Referencias:
1. Precio total para prestador nivel 3 de la base de datos Modalidad de Libre Elección 2018, FONASA.
Búsqueda y Síntesis de Evidencia
Búsqueda de costos
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluido |
|---|
Probablemente favorece la comparación: Considerando que la intervención es «realizar tamizaje con tomografía computarizada de tórax de baja dosis» y la comparación es «no realizar», el panel de expertos de la Guía opinó que probablemente la alternativa más costo-efectiva es «no realizar». Considerando la evidencia presentada y la disposición a pagar en Chile por año de vida ajustado por calidad (AVAC) ganado.
Evidencia de investigación
Se identificó 1 revisiones sistemáticas (1) y que incluía 9 estudios, en esta se concluye que la costo-efectividad del cribado con tomografía computarizada de dosis baja (TCBD) para el cáncer de pulmón es un tema muy debatible. El uso de TCBD para el cribado del cáncer de pulmón en comparación a no realizarlo, no fue rentable en cinco estudios cuando se consideró como estableció como umbral de la disposición a pagar de US$ 50.000 por años de vida ajustado por calidad (AVAC) ganados(2–6). La costo efectividad fue probada por dos estudios adicionales cuando el umbral se elevó a US $ 100.000 por AVAC (7,8) y por dos estudios adicionales cuando se elevó a US $ 150.000 por AVAC (7–10). La disposición a pagar en Chile que es de US$ 15.086(11).
Referencias
2. Pyenson BS, Henschke CI, Yankelevitz DF, Yip R, Dec E. Offering lung cancer screening to high-risk medicare beneficiaries saves lives and is cost-effective: an actuarial analysis. Am Heal drug benefits [Internet]. 2014 Aug [cited 2018 Sep 3];7(5):272–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25237423
3. Villanti AC, Jiang Y, Abrams DB, Pyenson BS. A Cost-Utility Analysis of Lung Cancer Screening and the Additional Benefits of Incorporating Smoking Cessation Interventions. Gorlova OY, editor. PLoS One [Internet]. 2013 Aug 7 [cited 2018 Sep 3];8(8):e71379. Available from: http://dx.plos.org/10.1371/journal.pone.0071379
4. Wisnivesky JP, Mushlin AI, Sicherman N, Henschke C. The cost-effectiveness of low-dose CT screening for lung cancer: preliminary results of baseline screening. Chest [Internet]. 2003 Aug [cited 2018 Sep 3];124(2):614–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12907551
5. Marshall D, Simpson KN, Earle CC, Chu CW. Economic decision analysis model of screening for lung cancer. Eur J Cancer [Internet]. 2001 Sep [cited 2018 Sep 3];37(14):1759–67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11549429
6. Shmueli A, Fraifeld S, Peretz T, Gutfeld O, Gips M, Sosna J, et al. Cost-Effectiveness of Baseline Low-Dose Computed Tomography Screening for Lung Cancer: The Israeli Experience. Value Heal [Internet]. 2013 Sep [cited 2018 Sep 3];16(6):922–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24041342
7. Black WC, Gareen IF, Soneji SS, Sicks JD, Keeler EB, Aberle DR, et al. Cost-Effectiveness of CT Screening in the National Lung Screening Trial. N Engl J Med [Internet]. 2014 Nov 6 [cited 2018 Sep 3];371(19):1793–802. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25372087
8. Manser R, Dalton A, Carter R, Byrnes G, Elwood M, Campbell DA. Cost-effectiveness analysis of screening for lung cancer with low dose spiral CT (computed tomography) in the Australian setting. Lung Cancer [Internet]. 2005 May [cited 2018 Sep 3];48(2):171–85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15829317
9. Mahadevia PJ, Fleisher LA, Frick KD, Eng J, Goodman SN, Powe NR. Lung cancer screening with helical computed tomography in older adult smokers: a decision and cost-effectiveness analysis. JAMA [Internet]. 2003 Jan 15 [cited 2018 Sep 3];289(3):313–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12525232
10. McMahon PM, Kong CY, Bouzan C, Weinstein MC, Cipriano LE, Tramontano AC, et al. Cost-Effectiveness of Computed Tomography Screening for Lung Cancer in the United States. J Thorac Oncol [Internet]. 2011 Nov [cited 2018 Sep 3];6(11):1841–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21892105
11. Ministerio de Salud de Chile. Guía Metodológica para la Evaluación Económica de Intervenciones en Salud en Chile [Internet]. Gobierno d. Santiago; 2013 [cited 2018 Jul 13]. 268 p. Available from: http://www.orasconhu.org/case/sites/default/files/files/EE_FINAL_web.pdf
Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de costo-efectividad
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Probablemente reducida: El panel de expertos de la Guía consideró que la equidad en salud se probablemente se reduciría si se recomendase «realizar tamizaje con tomografía computarizada de tórax de baja dosis». La equidad se vería reducida dado que es un examen moderadamente costoso y la disponibilidad del examen en la red asistencial pública es restringido.
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El panel de expertos de la Guía consideró que «realizar tamizaje con tomografía computarizada de tórax de baja dosis» probablemente SÍ es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos de centros de salud, pacientes, cuidadores, seguros de salud, otros).
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente no: El panel de expertos de la Guía consideró que «realizar tamizaje con tomografía computarizada de tórax de baja dosis» probablemente NO es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.
El TAC es una intervención costosa si se compara con otras intervenciones dirigidas a fumadores, como dejar de fumar. Además implicaría una demanda que sería dificil de cubrir con la disponibilidad de escáner en la red asitencial.