Is FDG PET/CT cost-effective for pre-operation staging of potentially operative non-small cell lung cancer? From Chinese healthcare system perspective

Objectives To assess the cost-effectiveness of FDG PET/CT in patients with potentially operative non-small cell lung cancer (NSCLC) in China.

Methods Management of NSCLC was modeled on decision analysis employing data in China. The strategies compared were conventional CT staging (strategy A), additional fluorodeoxyglucose positron emission tomography (FDG PET)/CT in all patients (strategy B) or only in patients with normal-sized lymph nodes on CT (strategy C). Published data including accuracies for detecting mediastinal lymph nodes for PET/CT and CT in China was extracted. The costs quoted corresponded to reimbursement in 2010 by the public health provider and followed the official guidelines for medical practice in China. Uncertainly of employed parameters were taken into account in sensitivity analysis.

Results Taking strategy A as baseline, the incremental cost-effectiveness ratio (ICER) of strategy B was 23,800 RMB(3500 dollars) per life year saved, within the commonly accepted range; while strategy C exhibited some loss of life years overall. Sensitivity analysis suggested the ICER (B-A) was more sensitive to a hypothetical deterioration of PET specificity than to its sensitivity. The ICER was turned negative by PET specificity lower than 0.79. Economically, a 20% raise of PET cost still led to an ICER within acceptable range (31,800 RMB/LYS), and decrease of palliative therapy cost, which was relatively high in China, could contribute to reduction of both ICER and overall cost per patient.

Conclusions This decision analysis modeling indicated the potential cost-effectiveness of the PET/CT strategy for management of NSCLC in China, with an acceptable ICER. Patients with nodal-positive CT results are not suggested to be excluded from further exams as PET/CT. Furthermore, maintaining high specificity of PET in clinical scenarios is crucial. Prospective studies are warranted to transfer these results into policy making.

Research Support National Natural Science Foundation of China, Project Number: 30830038, 81071180, 30970842; Shanghai Leading Academic Discipline Project, Project Number: S3020