Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.1055/s-0034-1392016
Managing incidental pancreatic cystic neoplasms with integrated molecular pathology is a cost-effective strategy
Publication History
submitted 13 February 2015
accepted after revision 02 March 2015
Publication Date:
26 June 2015 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00025476/201505/lookinside/thumbnails/179_10-1055-s-0034-1392016-1.jpg)
Background and study aims: Current guidelines recommend using endoscopic ultrasound (EUS), carcinoembryonic antigen (CEA) testing and cytology to manage incidental pancreatic cystic neoplasms (PCN); however, studies suggest a strategy including integrated molecular pathology (IMP) of cyst fluid may further aid in predicting risk of malignancy. Here, we evaluate several strategies for diagnosing and managing asymptomatic PCN using healthcare economic modeling.
Patients and methods: A third-party-payer perspective Markov decision model examined four management strategies in a hypothetical cohort of 1000 asymptomatic patients incidentally found to have a 3 cm solitary pancreatic cystic lesion. Strategy I used cross-sectional imaging, recommended surgery only if symptoms or risk factors emerged. Strategy II considered patients for resection without initial EUS. Strategy III (EUS + CEA + Cytology) referred only those with mucinous cysts (CEA > 192 ng/mL) for resection. Strategy IV implemented IMP; a commercially available panel provided a “Benign,” “Mucinous,” or “Aggressive” classification based on the level of mutational change in cyst fluid. “Benign” and “Mucinous” patients were followed with surveillance; “Aggressive” patients were referred for resection. Quality-adjusted life-years (QALY), relative risk with 95 %CI, Number Needed to Treat (NNT), and incremental cost-effectiveness ratios were calculated.
Results: Strategy IV provided the greatest increase in QALY at nearly identical cost to the cheapest approach, Strategy I. Relative risk of malignancy compared to the current standard of care and nearest competing strategy, Strategy III, was 0.18 (95 %CI 0.06 – 0.53) with an NNT of 56 (95 %CI 34 – 120).
Conclusions: Use of IMP was the most cost-effective strategy, supporting its routine clinical use.
-
References
- 1 Brugge WR, Lauwers GY, Sahani D et al. Cystic neoplasms of the pancreas. N Engl J Med 2004; 351: 1218-1226
- 2 Goh BK, Tan YM, Chung YF et al. Pancreatic cysts: a proposed management algorithm based on current evidence. Am J Surg 2007; 193: 749-755
- 3 Brugge WR, Lewandrowski K, Lee-Lewandrowski E et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004; 126: 1330-1336
- 4 Tanaka M, Fernandez-del CastilloC, Adsay V et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183-197
- 5 Khalid A, Brugge W. ACG practice guidelines for the diagnosis and management of neoplastic pancreatic cysts. Am J Gastroenterol 2007; 102: 2339-2349
- 6 Das A, Ngamruengphong S, Nagendra S et al. Asymptomatic pancreatic cystic neoplasm: a cost-effectiveness analysis of different strategies of management. Gastrointest Endosc 2009; 70: 690-699
- 7 Gaujoux S, Brennan MF, Gonen M et al. Cystic lesions of the pancreas: changes in the presentation and management of 1,424 patients at a single institution over a 15-year time period. J Am Coll Surg 2011; 212: 590-600
- 8 Fasanella KE, Krasinskas A, Schoedel KE et al. DNA mutational differences in cytological specimens from pancreatic cancer and cholangiocarcinoma. Pancreatology 2010; 10: 429-433
- 9 Khalid A, Zahid M, Finkelstein SD et al. Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study. Gastrointest Endosc 2009; 69: 1095-1102
- 10 Sawhney MS, Devarajan S, O'Farrel P et al. Comparison of carcinoembryonic antigen and molecular analysis in pancreatic cyst fluid. Gastrointest Endosc 2009; 69: 1106-1110
- 11 Shen J, Brugge WR, Dimaio CJ et al. Molecular analysis of pancreatic cyst fluid: a comparative analysis with current practice of diagnosis. Cancer 2009; 117: 217-227
- 12 Al-Haddad MA, Kowalski T, Siddiqui A et al. Integrated molecular pathology accurately determines the malignant potential of pancreatic cysts. Endoscopy 2015; 47: 136-146
- 13 American Society of Anesthesiologists. 2012 Relative Value Guide Book: a guide for anesthesia values. ASA Publications; 2012
- 14 Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Making 1993; 13: 322-338
- 15 Klose T. A utility-theoretic model for QALYs and willingness to pay. Health Econ 2003; 12: 17-31
- 16 Porter GA, Pisters PW, Mansyur C et al. Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann of Surg Oncol 2000; 7: 484-489
- 17 Rubenstein JH, Scheiman JM, Anderson MA. A clinical and economic evaluation of endoscopic ultrasound for patients at risk for familial pancreatic adenocarcinoma. Pancreatology 2007; 7: 514-525
- 18 Weinstein MC, Siegel JE, Gold MR et al. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 1996; 276: 1253-1258
- 19 Doubilet P, Begg CB, Weinstein MC et al. Probabilistic sensitivity analysis using Monte Carlo simulation. A practical approach. . Med Decis Making 1985; 5: 157-177
- 20 Gold M, Siegel J, Russell L, Weinstein MC (eds.). Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996
- 21 Heitjan DF. Fieller's method and net health benefits. Health Econ 2000; 9: 327-335
- 22 Stinnett AA, Mullahy J. Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med Decis Making 1998; 18: 68-80
- 23 Nagula S, Kennedy T, Schattner MA et al. Evaluation of cyst fluid CEA analysis in the diagnosis of mucinous cysts of the pancreas. J Gastrointest Surg 2010; 14: 1997-2003
- 24 Kucera S, Centeno BA, Springett G et al. Cyst fluid carcinoembryonic antigen level is not predictive of invasive cancer in patients with intraductal papillary mucinous neoplasm of the pancreas. JOP 2012; 13: 409-413
- 25 Fritz S, Klauss M, Bergmann F et al. Small (Sendai negative) branch-duct IPMNs: not harmless. Ann Surg 2012; 256: 313-320
- 26 Lee CJ, Scheiman J, Anderson MA et al. Risk of malignancy in resected cystic tumors of the pancreas ≤ 3 cm in size: is it safe to observe asymptomatic patients? A multi-institutional report. . J Gastrointest Surg 2008; 12: 234-242
- 27 Sahani DV, Saokar A, Hahn PF et al. Pancreatic cysts 3 cm or smaller: how aggressive should treatment be?. Radiology 2006; 238: 912-919
- 28 Inadomi JM, Somsouk M, Madanick RD et al. A cost-utility analysis of ablative therapy for Barrett's esophagus. Gastroenterology 2009; 136: 2101-2114 (e1 – 6)
- 29 Ganz RA. Barrett's esophagus. N Engl J Med 2010; 362: 1448-1449 author reply 1449
- 30 Gourgiotis S, Germanos S, Ridolfini MP. Presentation and management of pancreatic cystic neoplasms. J Clin Gastroenterol 2007; 41: 599-608