Sure. I might start since I might have been the guilty party who introduced that.
This is where Canada has the potential advantage over the U.S. The U.S. has not formalized a program, but it is paying for screening, which is covered as a Medicare benefit. So whether or not you organize a program depends on the centre that's offering the screening. Screening can be offered in your local community centre or you could have a van that goes around and offers screening. You don't necessarily have to tie outcomes, to cost-effectiveness, to quality, and to smoking cessation. What we've tried to do with CPAC, the Canadian Partnership Against Cancer, and the lung cancer framework is to set something up so that we are able to track statistics and outcomes. We are able to measure how many of the population at risk were able to get in, to actually have screening adherence rates, and also to tie this to smoking cessation.`
In terms of cost-effectiveness for the large U.S. randomized study, where no matter how early you found the cancer there was still a mortality benefit to treating it, the incremental cost-effectiveness ratio, which is a measure of benefit compared to cost was—and forgive me since I'm approximating here—somewhere between $83,000 and $86,000 U.S. per quality-adjusted life year gained. I'm happy to provide the committee with a reference and the paper for that. However, that is in the U.S. health care system. The way they have done that differs from the way our pan-Canadian study was done and from the way the framework is proposing that we do screening. So, cost-effectiveness estimates from Ontario from ICES that were commissioned by Cancer Care Ontario are as low as $43,000 or less per quality-adjusted life year. Again, depending on the interval of screening and the level of risk, your cost effectiveness impact can really change. So, yes, it will cost money. Could there be a way to introduce cost-effective screening by choosing your population and the follow-up? Yes, we think there is something within a reasonable estimate of cost-effectiveness.