Cost-effectiveness of FDG-PET for the management of potentially operable non-small cell lung cancer: priority for a PET-based strategy after nodal-negative CT results

Abstract

Decision analysis is used here to establish the most cost-effective strategy for management of potentially operable non-small cell lung cancers (NSCLCs). The strategies compared were conventional staging (strategy A), dedicated systems of positron emission tomography (PET) using fluorine-18 fluorodeoxyglucose (FDG) in patients with normal-sized (strategy B) or in patients with enlarged mediastinal lymph nodes (part of strategy C), and FDG-PET followed by exclusion from surgical procedures when both computed tomography (CT) and PET were positive for mediastinal lymph nodes (strategy D) or when PET alone was positive (strategy E). Based on published data, the sensitivity and specificity of FDG-PET were estimated at 0.74 and 0.96 for detecting metastasis in normal-sized mediastinal lymph nodes, and at 0.95 and 0.76 when these lymph nodes were enlarged. The calculated probability of up-staging to M1 by using PET was 0.05. The costs quoted correspond to the cost reimbursed in 1999 by the public health provider in Germany. The incremental cost-effectiveness ratio (ICER) of strategy B was much more favourable (143 EUR/LYS; LYS = life year saved) than the ICER of strategy C (36,667 EUR/LYS). In strategy B, the use of PET did not raise the overall costs because the costs of PET were almost balanced by a better selection of patients for beneficial cancer resection. The exclusion from biopsy confirmation in strategies D and E led to cost savings that did not justify the expected reduction in life expectancy. In sensitivity analyses, the ICERs of strategy B were robust to the pretest likelihood of N2/N3, to penalized test parameters of PET and to reimbursement of PET. However, the ICER of strategy B would be raised to 28,000 EUR/LYS through use of thoracic PET without whole-body scanning. To conclude, the implementation of whole-body PET with a full ring of detectors in the preoperative staging of patients with NSCLC and normal-sized lymph nodes is clearly cost-effective. However, patients with nodal-positive PET results should not be excluded from biopsy.

Pet Applications For Staging And Restaging In Thoracic Malignancies

“…FDG PET-BT için literatürde bildirilen bu olumlu sonuçlara rağmen, mediastinoskopi yerine bu noninvaziv yöntemin kullanılamayacağı ayrıca vurgulanmıştır (15,16). Mikrometastazlar nedeniyle literatürde %8'e varan yanlış negatif sonuçlar bildirilmiş olup, granü-lomatöz hastalıklar nedeni ile yanlış pozitif sonuçlar alınabileceği de yine akılda tutulmalıdır (17).…”

Investing in new technology: the PET experience

“…Briefly, a decision model attempts to reflect local surgical decisionmaking, cost structures and the impacts of both treatment and disease on quality of life, and to link the increased accuracy of PET to final outcomes through a decision-tree approach (Dietlein et al, 2000). The overall expected benefit from a number of alternative actions may then be compared, and that yielding the highest expected benefit selected as the most cost-effective strategy.…”

“…A number of such models of varying sophistication have been published for NSCLC (Gambhir et al, 1996;Scott et al, 1998;Dietlein et al, 2000). We chose to base our assessment of PET in early stage NSCLC on the Dietlein et al study, and amended it to take account of recently published accuracy data, costs within NHSScotland and local clinical opinion on how PET imaging would most likely be used.…”

PET/CT for staging lung cancer: costly or cost-saving?

“…Before the onset of hybrid PET/CT systems, the costeffectiveness of dedicated PET scanners had already been demonstrated by two independent studies [10,11]. Both groups could demonstrate that PET is cost-effective if mediastinal lymph node metastases can be detected in a patient with a normal chest CT, without evidence of suspicious nodes.…”