The clinical and economic impact of alternative staging strategies for adenocarcinoma of the pancreas

OBJECTIVE: Several innovative imaging modalities, including endoscopic ultr asound, have increased the number of available preoperative staging methods in patients with adenocarcinoma of the pancreas. Our goal was to estimate the clinical outcomes and cost-effectiveness of alternative staging strateg ies for pancreatic adenocarcinoma. METHODS: Decision analysis was used to simulate alternative staging strateg ies. Cost inputs were based on Medicare reimbursements; clinical inputs wer e obtained from the available literature. Model endpoints of interest were cost per curative resection and appropriateness of treatment allocation bas ed on pathological stage. RESULTS: Endoscopic ultrasound followed by laparoscopy yielded the lowest c ost per curative resection ($37,600) and minimized the number of unnecessar y surgical explorations (5.4 per 100 patients staged). Requiring angiograph ic confirmation when endoscopic ultrasound demonstrated an unresectable tum or yielded an intermediate cost-effectiveness ratio and virtually eliminate d the risk of overstaging. Laparoscopy alone maximized the resection rate, but each additional resection would cost approximately $2 million relative to a strategy employing both endoscopic ultrasound and angiography. CONCLUSIONS: Staging strategies incorporating endoscopic ultrasound may imp rove treatment allocation and are cost-effective relative to angiography-ba sed strategies. A staging protocol that does not incorporate an imaging mod ality to detect vascular invasion dramatically increases the cost per addit ional curative resection compared with more comprehensive staging protocols . (C) 2000 by Am. Cell. of Gastroenterology.