Evaluating Multi-Cancer Early Detection (MCED) in Medicare: Cost-Effectiveness and Policy Pathways for Pancreatic Cancer

Abstract

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers. Most patients enter the clinical pathway at an advanced stage, long after symptoms have appeared, which limits treatment options and survival. Multi-Cancer Early Detection (MCED) tests that examine methylation patterns in circulating cell-free DNA offer a possible route toward earlier, more actionable diagnoses. Even with that promise, questions remain about the true economic value of these tests and the feasibility of Medicare coverage for the populations that may need them most. This dissertation used a convergent parallel mixed-methods design to examine these questions. The quantitative analysis relied on a patient-level microsimulation built from nine confirmed Stage II and III PDAC cases, each supported by real-world billing data. The model was expanded through 30,000 Monte Carlo replications to test stability and ranges of possible outcomes. The average cost per patient was $177,691. When applied to the 67,440 projected incident PDAC cases in 2025, this produced a conservative lower-bound estimate of about $12.0 billion in national direct medical spending. Stage-weighted modeling showed that most of these costs come from distant-stage disease, which accounts for more than three-quarters of total spending. When adjusted to the share of Medicare beneficiaries, the estimated Medicare-attributable spending ranged from $7.2 to $9.6 billion each year. The qualitative analysis examined eight elite interviews with congressional staff conducted between February and July 2025. By the eighth interview, thematic saturation had been reached, producing 21 themes across fiscal, clinical, and policy areas. Staff from both parties raised persistent concerns about Medicare solvency and emphasized the need for strong fiscal safeguards in any new coverage pathway. PDAC was viewed as a compelling application for MCED because of its severity, limited early detection options, and the high costs associated with late-stage care. Across offices, Coverage with Evidence Development (CED) emerged as a feasible policy pathway, supported by constituent stories and earlier precedents in colorectal screening tools. Convergent integration of the two strands demonstrated how the cost modeling and policy perspectives align. Both strands identified Stage III PDAC as a major source of economic and clinical burden, and congressional staff viewed feasibility through the lens of Medicare solvency and patient access. CED appeared as a shared mechanism that could balance early innovation with careful fiscal oversight. Bringing together health economics and elite interviewing illustrated how policy feasibility can be assessed in a practical way. The findings suggest that MCED for PDAC may be both economically and politically feasible when directed toward high-risk populations within a Medicare CED pathway, creating an opportunity to support earlier detection in a cancer that remains one of the most urgent challenges.