Computed tomography and positron emission tomography/computed tomography surveillance after combined modality treatment of supradiaphragmatic Hodgkin lymphoma: a clinical and economic perspective

Abstract

We studied the clinical benefits of radiological imaging, in the follow-up of patients after combined modality treatment for stage I/II classical supradiaphragmatic Hodgkin lymphoma (HL). Imaging data were collected for 78 adults treated during 1996-2008. Median follow-up was 4.6 years. Six of the nine relapses were detected clinically. On average, 31 imaging studies/patient were performed, with an estimated cost of $12 608/patient. Chest computed tomography (CT) scans accounted for 25%, abdominopelvic CT scans 41% and positron emission tomography (PET) or PET/CT scans 22% of this expense. Only one patient recurred infradiaphragmatically. The estimated radiation dose from imaging was 399 mSv and 229 mSv per patient, in relapse and non-relapse groups, respectively. CT scans contributed over 80% of the imaging radiation exposure. The routine use of CT scans in the surveillance of patients with HL after curative treatment adds to healthcare costs and total body radiation exposure with a low yield. History and physical examination remain effective tools for the follow-up of patients.

Very low utility of surveillance imaging in early‐stage classic Hodgkin lymphoma treated with a combination of doxorubicin, bleomycin, vinblastine, and dacarbazine and radiation therapy

“…Our 2 studies were confined to patients with CD20-negative early-stage cHL and a complete metabolic response on interim or post-ABVD PET. This is in contrast to the 10% to 15% relapse rates reported in prior studies (Table 3), 22,32–35 which did not perform end-of-treatment PET in all patients 32 or included patients with positive end-of-treatment PET. 34,35 Notably, because residual FDG avidity at the completion of first-line therapy is associated with a higher risk of relapse, 38 the utility of surveillance imaging should be studied separately for patients with positive end-of-treatment PET/CT.…”

“…8,9 Chest X-rays and CT scans are recommended, although most HL relapses are detected on the basis of clinical suspicion or patientreported symptoms rather than imaging. [18][19][20][21][22][23][24] The increasing use of medical imaging has also led to concerns about the potential long-term biologic effects of ionizing radiation, particularly in young patients with early-stage cHL who have a high probability of long-term survival. 1,25,26 On the basis of our prior work, 27 we investigated the utility of any surveillance imaging in patients with early-stage cHL treated with CMT who achieved a complete metabolic response according to either interim or postchemotherapy PET/CT.…”

Limited utility of routine surveillance imaging for classical Hodgkin lymphoma patients in first complete remission

“…For patients with advanced‐stage disease, they concluded that annual CT follow‐up would be associated with a very small gain in quality‐adjusted life‐years over non‐CT follow‐up, with an incremental cost‐effectiveness ratio of greater than $9,000,000 per quality‐adjusted life‐year gained . Another recently published study estimated a cost of $12,608 per patient for surveillance imaging in individuals with supradiaphragmatic disease based on Medicare reimbursement . Our estimate of nearly $18,000 charged per patient in the routine surveillance group is in agreement with that study, because Medicare reimbursements typically are lower than the amount charged to third‐party health insurance.…”

“…21 Another recently published study estimated a cost of $12,608 per patient for surveillance imaging in individuals with supradiaphragmatic disease based on Medicare reimbursement. 22 Our estimate of nearly $18,000 charged per patient in the routine surveillance group is in agreement with that study, because Medicare reimbursements typically are lower than the amount charged to third-party health insurance.…”

Guidelines for the first line management of classical Hodgkin lymphoma

“…Some patients/clinicians may prefer early discharge from formal follow-up after completion of first line therapy. Routine CT or PET/CT scans significantly increase radiation exposure and health care costs with no clear evidence of benefit for patients (Voss et al, 2012;Patel et al, 2013). As such, routine CT or PET/CT scanning for otherwise well patients is not normally required.…”