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

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.