Cost-Effectiveness of Dotatate PET/MRI for Radiation Treatment Planning in Patients with Intermediate-Risk Meningioma

Purpose: Approximately 20 to 35% of meningiomas are classified as World Health Organization (WHO) grade II or III, conferring increased risk of recurrence and lower overall survival. Accurate imaging is particularly important in this patient population, as postoperative scarring can confound the interpretation of conventional contrast-enhanced MRI. Somatostatin receptor 2 (SSTR2) is overexpressed in meningiomas, with very low expression in normal brain, meninges, and cranial soft tissues, allowing tumor visualization with positron emission tomography (PET) using somatostatin analogues such as Ga68-DOTATATE. DOTATATE PET has previously demonstrated superiority in the detection of postoperative recurrence as well as delineation of osseous and parenchymal invasion compared with MRI. While PET/MRI confers a higher cost of imaging compared with MRI alone, it has the potential of saving healthcare costs through decreasing radiation volumes (and thereby number of visits), as well as decreasing associated morbidity. Our purpose was to perform cost-effectiveness analysis of PET/MR in patients with intermediate-risk meningioma undergoing radiotherapy planning.

Materials and Methods: We performed a cost-effectiveness analysis of DOTATATE-PET/MRI or PET/CT for planning of radiotherapy in recurrent benign and malignant (intermediate-risk) meningiomas using a decision model to compare the effectiveness in terms of quality-adjusted life years (QALYs) and costs. PET/MRI or PET/CT was considered the “new strategy” and MRI was considered the “standard strategy.” Radiotherapy guidelines for intermediate-risk meningiomas were based on the NRG Oncology phase-II trial (RTOG 0539). The clinical outcomes were categorized in two groups: none-to-minor disability, and moderate-to-severe disability. The probabilities for progression and clinical outcomes with each strategy were determined based on published studies. The probabilities assigned for the development of progression and clinical outcomes in patients who underwent DOTATATE PET for RT planning were derived from a prospective cohort at our institution. Additionally, probabilities for the standard strategy were derived from a retrospective institutional cohort. The endpoint costs included in the decision model were those of radiotherapy, disability, and those of the standard and new imaging strategy. One-way sensitivity analyses were performed. A willingness-to-pay (WTP) threshold of $100,000 was assumed.

Results: The per-person cost for the PET/MRI (new) strategy was $349,067. The per-person cost for the MRI (standard) strategy was $889,079. The new strategy resulted in a gain of 21.28 QALYs. The standard strategy resulted in a gain of 18.11 QALYs. Because the PET/MRI strategy resulted in lower costs and higher QALYs gained, it was dominant over the standard strategy. Our results remained robust when varying multiple variables across a range of 0 to 1.

Conclusion: DOTATATE PET/MRI has recently been demonstrated to convey added benefits in the evaluation and treatment planning of meningiomas, particularly those in the intermediate-risk group. Our pilot cost-effectiveness analysis model demonstrated DOTATATE PET/MRI to be dominant over MRI alone, with higher QALYs and lower costs. Limitations of the study, to be addressed in future work, include the small cohort size and lack of long-term follow-up data of our institutional cohort. Our pilot data supports the use of DOTATATE PET/MRI in the management of intermediate-risk meningiomas.

Decision Model

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Publication History

Article published online:
12 February 2021