Skip to main content

Advertisement

SpringerLink
Log in

Preoperative staging of lung cancer with PET/CT: cost-effectiveness evaluation alongside a randomized controlled trial

  • Original Article
  • Published:
European Journal of Nuclear Medicine and Molecular Imaging Aims and scope Submit manuscript

Abstract

Purpose

Positron emission tomography (PET)/CT has become a widely used technology for preoperative staging of non-small cell lung cancer (NSCLC). Two recent randomized controlled trials (RCT) have established its efficacy over conventional staging, but no studies have assessed its cost-effectiveness. The objective of this study was to assess the cost-effectiveness of PET/CT as an adjunct to conventional workup for preoperative staging of NSCLC.

Methods

The study was conducted alongside an RCT in which 189 patients were allocated to conventional staging (n = 91) or conventional staging + PET/CT (n = 98) and followed for 1 year after which the numbers of futile thoracotomies in each group were monitored. A full health care sector perspective was adapted for costing resource use. The outcome parameter was defined as the number needed to treat (NNT)—here number of PET/CT scans needed—to avoid one futile thoracotomy. All monetary estimates were inflated to 2010 €.

Results

The incremental cost of the PET/CT-based regimen was estimated at 3,927 € [95% confidence interval (CI) −3,331; 10,586] and the NNT at 4.92 (95% CI 3.00; 13.62). These resulted in an average incremental cost-effectiveness ratio of 19,314 €, which would be cost-effective at a probability of 0.90 given a willingness to pay of 50,000 € per avoided futile thoracotomy. When costs of comorbidity-related hospital services were excluded, the PET/CT regimen appeared dominant.

Conclusion

Applying a full health care sector perspective, the cost-effectiveness of PET/CT for staging NSCLC seems to depend on the willingness to pay in order to avoid a futile thoracotomy. However, given that four outliers in terms of extreme comorbidity were all randomized to the PET/CT arm, there is uncertainty about the conclusion. When hospital costs of comorbidity were excluded, the PET/CT regimen was found to be both more accurate and cost saving.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Fischer B, Lassen U, Mortensen J, Larsen S, Loft A, Bertelsen A, et al. Preoperative staging of lung cancer with combined PET-CT. N Engl J Med 2009;361(1):32–9.

    Article  PubMed  CAS  Google Scholar 

  2. Maziak DE, Darling GE, Inculet RI, Gulenchyn KY, Driedger AA, Ung YC, et al. Positron emission tomography in staging early lung cancer: a randomized trial. Ann Intern Med 2009;151:221–8.

    PubMed  Google Scholar 

  3. Scott WJ, Shepherd J, Gambhir SS. Cost-effectiveness of FDG-PET for staging non-small cell lung cancer: a decision analysis. Ann Thorac Surg 1998;66(6):1876–83.

    Article  PubMed  CAS  Google Scholar 

  4. Dietlein M, Weber K, Gandjour A, Moka D, Theissen P, Lauterbach KW, 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 Med 2000;27(11):1598–609.

    Article  PubMed  CAS  Google Scholar 

  5. Hayashi K, Abe K, Yano F, Watanabe S, Iwasaki Y, Kosuda S. Should mediastinoscopy actually be incorporated into the FDG PET strategy for patients with non-small cell lung carcinoma? Ann Nucl Med 2005;19(5):393–8.

    Article  PubMed  Google Scholar 

  6. Alzahouri K, Lejeune C, Woronoff-Lemsi MC, Arveux P, Guillemin F. Cost-effectiveness analysis of strategies introducing FDG-PET into the mediastinal staging of non-small-cell lung cancer from the French healthcare system perspective. Clin Radiol 2005;60(4):479–92.

    Article  PubMed  CAS  Google Scholar 

  7. Nguyen VH, Peloquin S, Lacasse Y. Cost-effectiveness of positron emission tomography for the management of potentially operable non-small cell lung cancer in Quebec. Can Respir J 2005;12(1):19–25.

    PubMed  Google Scholar 

  8. Gambhir SS, Hoh CK, Phelps ME, Madar I, Maddahi J. Decision tree sensitivity analysis for cost-effectiveness of FDG-PET in the staging and management of non-small-cell lung carcinoma. J Nucl Med 1996;37(9):1428–36.

    PubMed  CAS  Google Scholar 

  9. Bradbury I, Bonell E, Boynton J, et al. Positron emission tomography (PET) imaging in cancer management. Glasgow: Health Technology Board for Scotland; 2002.

    Google Scholar 

  10. The diagnosis and treatment of lung cancer. London: National Institute for Clinical Excellence; 2005.

  11. Bird A, Norman R, Goodall S. Economic evaluation of positron emission tomography (PET) in non small cell lung cancer (NSCLC). Sidney: CHERE; 2007.

    Google Scholar 

  12. Kosuda S, Ichihara K, Watanabe M, Kobayashi H, Kusano S. Decision-tree sensitivity analysis for cost-effectiveness of chest 2-fluoro-2-D-[(18)F]fluorodeoxyglucose positron emission tomography in patients with pulmonary nodules (non-small cell lung carcinoma) in Japan. Chest 2000;117(2):346–53.

    Article  PubMed  CAS  Google Scholar 

  13. Verboom P, van Tinteren H, Hoekstra O, Smit E, van den Bergh J, Schreurs A, et al. Cost-effectiveness of FDG-PET in staging non-small cell lung cancer: the PLUS study. Eur J Nucl Med Mol Imaging 2003;30(11):1444–9.

    Article  PubMed  Google Scholar 

  14. Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest 1997;111(6):1710–7.

    Article  PubMed  CAS  Google Scholar 

  15. Altman DG. Confidence intervals for the number needed to treat. BMJ 1998;317(7168):1309–12.

    PubMed  CAS  Google Scholar 

  16. Barber JA, Thompson SG. Analysis of cost data in randomized trials: an application of the non-parametric bootstrap. Stat Med 2000;19(23):3219–36.

    Article  PubMed  CAS  Google Scholar 

  17. Carpenter J, Bithell J. Bootstrap confidence intervals: when, which, what? A practical guide for medical statisticians. Stat Med 2000;19(9):1141–64.

    Article  PubMed  CAS  Google Scholar 

  18. Buck AK, Herrmann K, Stargardt T, Dechow T, Krause BJ, Schreyögg J. Economic evaluation of PET and PET/CT in oncology: evidence and methodologic approaches. J Nucl Med 2010;51(3):401–12.

    Article  PubMed  Google Scholar 

  19. Hoch JS, Briggs AH, Willan AR. Something old, something new, something borrowed, something blue: a framework for the marriage of health econometrics and cost-effectiveness analysis. Health Econ 2002;11(5):415–30.

    Article  PubMed  Google Scholar 

  20. Stinnett AA, Mullahy J. Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med Decis Making 1998;18:S68–80.

    Article  PubMed  CAS  Google Scholar 

  21. Drummond MF. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford: Oxford University Press; 2005.

    Google Scholar 

  22. Kristiansen IS, Gyrd-Hansen D. Cost-effectiveness analysis based on the number-needed-to-treat: common sense or non-sense? Health Econ 2004;13(1):9–19.

    Article  PubMed  Google Scholar 

  23. Wallace MB, Nietert PJ, Earle C, Krasna MJ, Hawes RH, Hoffman BJ, et al. An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron emission tomography, and thoracoscopy/laparoscopy. Ann Thorac Surg 2002;74(4):1026–32.

    Article  PubMed  Google Scholar 

  24. Hövels AM, Heesakkers RAM, Adang EMM, Barentsz JO, Jager GJ, Severens JL. Cost-effectiveness of MR lymphography for the detection of lymph node metastases in patients with prostate cancer. Radiology 2009;252(3):729–36.

    Article  PubMed  Google Scholar 

  25. Biccard BM, Sear JW, Foëx P. The pharmacoeconomics of peri-operative beta-blocker therapy. Anaesthesia 2006;61(1):4–8.

    Article  PubMed  CAS  Google Scholar 

  26. Shermock KM, Horn E, Lipsett PA, Pronovost PJ, Dorman T. Number needed to treat and cost of recombinant human erythropoietin to avoid one transfusion-related adverse event in critically ill patients. Crit Care Med 2005;33(3):497–503.

    Article  PubMed  CAS  Google Scholar 

  27. Buck A, Halter G, Schirrmeister H, Kotzerke J, Wurziger I, Glatting G, et al. Imaging proliferation in lung tumors with PET: 18F-FLT versus 18F-FDG. J Nucl Med 2003;44(9):1426–31.

    PubMed  CAS  Google Scholar 

  28. Herder GJ, Kramer H, Hoekstra OS, Smit EF, Pruim J, van Tinteren H, et al. Traditional versus up-front [18F] fluorodeoxyglucose-positron emission tomography staging of non-small-cell lung cancer: a Dutch cooperative randomized study. J Clin Oncol 2006;24(12):1800–6.

    Article  PubMed  Google Scholar 

  29. Vilmann P, Annema J, Clementsen P. Endosonography in bronchopulmonary disease. Best Pract Res Clin Gastroenterol 2009;23(5):711–28.

    Article  PubMed  Google Scholar 

Download references

Acknowledgement

The contribution to this study from all of the members in the PERALUST study group is respectfully acknowledged. The following colleagues contributed significantly to this project: S. Larsen from Hvidovre Hospital; A. Loft, AK. Bertelsen, J. Ravn, I. Steffensen and G. Jacobsen from Rigshospitalet, Copenhagen University Hospital, Copenhagen; P. Clementsen, A. Dirksen, P. Vilmann, N. Maltbæk and J. Pedersen from Gentofte Hospital, Copenhagen; A. Hoegholm from Næstved Hospital, Næstved; KR. Larsen, BG. Skov, H. Hansen, V. Backer and H. Nielsen from Bispebjerg Hospital, Copenhagen; TR. Rasmussen, S. Keiding and H. Madsen from Århus Hospital, Århus; O. Gerke, Odense University Hospital, Odense.

This work was funded by a grant from The Danish Cancer Society (application no. R2-A299-B239). Thank you to the John and Birthe Meyer Foundation for providing the PET/CT scanner.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Centre for Health Service Research and Technology Assessment, University of Southern Denmark, Copenhagen, Denmark

    Rikke Søgaard

  2. Department for Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

    Barbara Malene B. Fischer, Jann Mortensen & Liselotte Højgaard

  3. Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark

    Jann Mortensen & Liselotte Højgaard

  4. Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

    Ulrik Lassen

  5. Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Kettegård Allé 30, 2650, Hvidovre, Denmark

    Barbara Malene B. Fischer

Authors
  1. Rikke Søgaard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Barbara Malene B. Fischer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jann Mortensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Liselotte Højgaard
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ulrik Lassen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Barbara Malene B. Fischer.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Søgaard, R., Fischer, B.M.B., Mortensen, J. et al. Preoperative staging of lung cancer with PET/CT: cost-effectiveness evaluation alongside a randomized controlled trial. Eur J Nucl Med Mol Imaging 38, 802–809 (2011). https://doi.org/10.1007/s00259-010-1703-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00259-010-1703-y

Keywords

Search

Navigation