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
M. Dietlein et al., 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, EUR J NUCL, 27(11), 2000, pp. 1598-1609
Citations number
46
Categorie Soggetti
Radiology ,Nuclear Medicine & Imaging","Medical Research Diagnosis & Treatment
Decision analysis is used here to establish the most cost-effective strateg
y for management of potentially operable non-small cell lung cancers (NSCLC
s). The strategies compared were conventional staging (strategy A), dedicat
ed systems of positron emission tomography (PET) using fluorine-18 fluorode
oxyglucose (FDG) in patients with normal-sized (strategy B) or in patients
with enlarged mediastinal lymph nodes (part of strategy C), and FDG-PET fol
lowed 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 sensitivi
ty 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 w
hen these lymph nodes were enlarged. The calculated probability of up-stagi
ng to MI by using PET was 0.05. The costs quoted correspond to the cost rei
mbursed in 1999 by the public health provider in Germany. The incremental c
ost-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 th
e costs of PET were almost balanced by a better selection of patients for b
eneficial cancer resection. The exclusion from biopsy confirmation in strat
egies D and E led to cost savings that did not justify the expected reducti
on in life expectancy. In sensitivity analyses, the ICERs of strategy B wer
e robust to the pretest likelihood of N2/N3, to penalized test parameters o
f 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 sc
anning. 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-p
ositive PET results should not be excluded from biopsy.