Cost-effectiveness of PET for the management of lung tumours: Comparison of economic data

Summary

Modelling is an accepted, valid and often necessary method for assessing economic effectiveness in terms of cost per life year gained. Comparing an alternative strategy (a) with a baseline strategy (bl), the incremental cost (C0ST_a-C0ST_b|) divided by the incremental life expectancy (LE_G-LE_bï) defines the incremental cost-effectiveness ratio (ICER). Taking watchful waiting as the low-cost baseline strategy for the management of solitary pulmonary nodules, the ICER of positron emission tomography (PET) [3218 euros (EUR) per life year saved (LYS)] was more favourable than that of exploratory surgery (4210 EUR/LYS) or that of transthoracic needle biopsy (6120 EUR/LYS). Changing the baseline strategy to exploratory surgery, the use of PET led to cost savings and additional life expectancy in case of an intermediate pretest probability of malignancy. For management of potentially operable non-small cell lung cancer the use of PET in patients with normalisized mediastinal lymph nodes on CT was most cost-effective (143 EUR/LYS), and the costs of PET were almost balanced by a better selection of patients for beneficial cancer resection. Using PET in patients with enlarged lymph nodes on CT, the ICER raised to 36,667 EUR/LYS. When PET or CT were positive for mediastinal lymph nodes, the exclusion from biopsy confirmation led to cost savings that did not justify the expected reduction in life expectancy. Economic data from the USA and Japan also demonstrated the cost-effectiveness of PET-based algorithms for the management of lung tumours.

Zusammenfassung

Die Entscheidungsmodellierung ist eine in der Gesundheitsökonomie anerkannte und häufig notwendige Methode, um die Kosten in Relation zu den gewonnenen Lebensjahren bewerten zu können. Wird eine alternative Strategie (a) mit einer Basisstrategie (b) verglichen, so definiert die Kostendifferenz (K0STEN_G-K0STEN_b) geteilt durch die Differenz in der Lebenserwartung (LE_G-LE_b) die “incremental cost-effectiveness ratio” (ICER). Solange das kontrollierte Zuwarten die Basisstrategie bei der Dig-nitätsabklärung des solîtaren Lungenrundherdes darstellte, lag die ICER der Positronen-Emissions-Tomographie (PET) (3218 Euros [EUR] pro gewonnenes Lebensjahr [LYS = life year saved]) günstiger als die ICER der ex-plorativen Chirurgie (4210 EUR/LYS) oder die ICER der Feinnadelbiopsie (6120 EUR/LYS). Bildete die explorative Chirurgie die Basisstrategie, führte der PET-Algorith-mus zur Kostenreduktion und zu einem Lebenszeitgewinn, eine mittlere Vortestwahrscheinlichkeit für Malignität vorausgesetzt. Bei der Behandlung des potenziell operablen, nicht-kleinzelligen Bronchialkarzinoms erwies sich die PET bei Patienten mit normal großen me-diastinalen Lymphknoten im CT als sehr kosteneffektiv (143 EUR/LYS). Die Kosten der PET wurden durch die verbesserte Patientenauswahl zur primären Tumorresektion nahezu kompensiert. Bei Patienten mit nodal-positi-vem CT stieg die ICER auf 36 667 EUR/LYS: Nodal-positive PET- oder CT-Befunde bedurften der histologischen Verifizierung. Andernfalls ergäbe sich eine durch die ICERs nicht gerechtfertigte Verminderung der Lebenserwartung. Die gesundheitsökonomischen Daten aus den USA und Japan sprechen ebenfalls für eine Kosteneffek-livität der PET-basierten Algorithmen bei der Behandlung der Lungentumoren.

Keywords

Cost-effectiveness - economics - PET - lung

Schlüsselwörter

Kosteneffektivität - Ökonomie - PET - Lunge

• Literatur

• 1 Bares R, Grün B, Fass J. et al. Kosten-Nutzen-Analyse der Immun- und Rezeptorszintigra-phie am Beispiel der Diagnose von Rektum-Karzinomen und Karzinoiden. Nuklearmediziner 1996; 19: 60-8.
• 2 Bleckmann C, Buchert R, Schulte U. et al. Onco-PET: lesion detection by computer display versus standardized documentation on film. Nuklearmedizin 1999; 38: 56-60.
• 3 Briele B, Willkomm P, Grünwald F. et al. Imaging of secondary pulmonary changes in central bronchial carcinoma by F-18-FDG-PET. Nuklearmedizin 1999; 38: 323-7.
• 4 Brix G, Henze M, Doll J. et al. Diagnostic evaluation of the breast using PET: optimization of data acquisition and postprocessing. Nuklearmedizin 2000; 39: 62-6.
• 5 Cremerius U, Fabry U, Neuerburg J. et al. Prognostic significance of positron emission tomography using fluorine-18-fluorodeoxyglucose in patients treated for malignant lymphoma. Nuklearmedizin 2001; 40: 23-30.
• 6 Dietlein M, Knapp WH, Lauterbach KW, Schicha H. Economic evaluation studies in nuclear medicine: the need for standardization. EurJNucI Med 2000; 26: 663-80.
• 7 Dietlein M, Weber K, Gandjour A. et al. Cost-effectiveness of FDG-PET for the management of solitary pulmonary nodules: a decision analysis based on cost reimbursement in Germany. Eur J Nucl Med 2000; 27: 1441-56.
• 8 Dietlein M, Weber K, Gandjour A. et al. Cost-effectiveness of FDG-PET for the management of the surgically treatable non-small cell lung cancer (NSCLC): Priority for a PET-based strategy after nodale negative CT results. Eur J Nucl Med 2000; 27: 1598-609.
• 9 Dwamena BA, Sonnad SS, Angobaldo JO, Wahl RL. Metastases from non-small cell lung cancer: mediastinal staging in the 1990s - Meta-analytic comparison of PET and CT. Radiology 1999; 213: 530-6.
• 10 Gambhir SS, Höh CK, Phelps ME. et al. Decision tree analysis for cost-effectiveness of FDG-PET in the staging and management of non-small-cell lung carcinoma. J Nucl Med 1996; 37: 1428-36.
• 11 Gambhir SS, Shepherd JE, Shah BD. et al. Analytical decision model for the management of solitary pulmonary nodules. J Clin Oncol 1998; 16: 2113-25.
• 12 Goerres GW, Haenggeli CA, Allaoua M. et al. Direct comparison of F-18-FDG PET and ultrasound in the follow-up of patients with squamous cell cancer of the head and neck. Nuklearmedizin 2000; 39: 246-50.
• 13 Kalff V, Hicks RJ, MacManus MP. et al. Clinical impact of ^l8F fluorodeoxyglucose positron emission tomography in patients with non-small-cell lung cancer: a prospective study. J Clin Oncol 2001; 19: 111-8.
• 14 Knapp WH. Leitlinie zur Tumordarstellung mit (F-lS)-Fluordeoxyglukose (FDG). Nuklearmedizin 1999; 38: 267-9.
• 15 Kosuda S, Ichihara K, Watanabe M. et al. Decision-tree sensitivity analysis for cost-effectiveness of chest 2-Fluoro-2-D-[^l8F]fluorodeoxy-glucose positron emission tomography in patients with pulmonary nodules (non-small cell lung cancer) in Japan. Chest 2000; 117: 346-53.
• 16 Lottes G, Schober O. Costs of F-18-FDG-PET with a satellite concept: update. Nuklearmedizin 2000; 39: 72-6.
• 17 Pieterman RM, Putten van JWG, Meuzelaar JJ. et al. Preoperative staging of non-small cell lung cancer with positron-emission tomography. N Engl J Med 2000; 343: 254-61.
• 18 Reinartz P, Zimny M, Cremerius U. et al. Quantification of repositioning errors in PET-studies through superposition of emission and transmission scan. Nuklearmedizin 1999; 38: 192-8.
• 19 Santambrogio L, Nosotti M, Bellaviti N. et al. CT-guided fine-needle aspiration cytology of solitary pulmonary nodules: a prospective, randomized study of immediate cytologic evaluation. Chest 1997; 112: 423-5.
• 20 Schaefer A, Kremp S, Hellwig D. et al. Influence of single-photon-transmission scan duration measured with the ECAT ART PET-scanner. Nuklearmedizin 2000; 39: 156-65.
• 21 Scott WJ, Shepherd J, Gambhir SS. Cost-effectiveness for FDG-PET for staging non-small cell lung cancer: a decision analysis. Ann Thorac Surg 1998; 66: 1876-85.
• 22 Tengs TO, Adams ME, Pliskin JS. et al. Five-hundred life-saving interventions and their cost-effectiveness. Risk Anal 1995; 15: 369-90.
• 23 Toomes H, Delphendahl A, Manke HG. et al. The coin lesion of the lung. A review of 955 resected coin lesions. Cancer 1983; 51: 534-7.
• 24 Viggiano RW, Swensen SJ, Rosenow EC. Evaluation and management of solitary and multiple pulmonary nodules. Clin Chest Med 1992; 13: 83-95.
• 25 Wright JC, Weinstein MC. Gains in life expectancy from medical interventions - standardizing data on outcomes. N Engl J Med 1998; 339: 380-6.
• 26 Zimny M, Kaiser HJ, Cremerius U. et al. F-18-FDG positron imaging in oncological patients: gamma camera coincidence detection versus dedicated PET. Nuklearmedizin 1999; 38: 108-14.