Preoperative staging of lung cancer with PET/CT: cost-effectiveness evaluation alongside a randomized controlled trial
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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.
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 €.
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.
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.
KeywordsPET/CT Cost-effectiveness Lung cancer staging Randomized controlled trial
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
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