26
Cost-Effectiveness FDG-PET in Lung Cancer Staging

Cost-Effectiveness FDG-PET in Lung Cancer Staging

Embed Size (px)

Citation preview

Page 1: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Cost-Effectiveness

FDG-PET in

Lung Cancer Staging

Page 2: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Small cell cancer 20~25% Squamous ca 30~35% Adenocarcinoma 30~35% Large cell ca 15~20%

BackgroundEpidemiology of Lung Cancer

15% of all cancer in USA Yearly new cases: 3 mill. wordwide, 0.18 mill. USA

NSCLC

Single most important prognostic factor in NSCLC = resectability Resectable in 20~35% of NSCLC patients.

결핵 및 호흡기 질환 1999

Page 3: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Staging of NSCLC

IA T1N0M0 67 +

IB T2N0M0 57 +

IIA T1N1M0 55 +

IIB T2N1M0

T3N0M0

IIIA T3N1M0

T1~3N2M0

IIIB T1~4N3M0

T4N0~2M0

IV any M1 1 –

Stage Definition 5Y surv(%) Resectability

38~39

23~25

1~8

+

N3

N2

++

Page 4: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Peribronchial LN

Ipsilateral hilar LN

Intrapulmonary LN

N1

Ipsilateral mediastinal LN

Subcarinal LN

N2

Contralateral mediastinal

Contralateral hilar LN

Supraclavicular LN

N3

Page 5: Cost-Effectiveness FDG-PET in Lung Cancer Staging

CT in NSCLC Staging

CT is the standard method for screening for LN involvement

Meta-analysis of 42 studies: 79% SN, 78% SP More recent reports : 52-64% SN, 62-69% SP

CT accuracy for LN assessment

Variation in normal LN size range Reactive hyperplasia or infection related enlargement LN not enlarged with microsccopic metastasis Poor inter-observer kappa value for size assessment

Limitations of LN assessment with CT

Page 6: Cost-Effectiveness FDG-PET in Lung Cancer Staging

FDG PET in NSCLC Staging

Meta-analysis : 87% SN, 95% SP

PET accuracy for LN assessment

Detect metastasis in non-enlarged LNs Exclude metastasis in enlarged LNs

Potential role of PET in LN staging

Page 7: Cost-Effectiveness FDG-PET in Lung Cancer Staging

FDG PET Staging in ROK

Total N = 20 Biopsy N = 17 N0 11; N1 2; N2 4 CT : SN 50%; SP 47% PET: SN 83%; SP 73%

Total N = 25 Biopsy N = 25 LN stage ? CT : accuracy 56% PET: accuracy 76%

SNUH, FDG PET, 1997

Ajou U, CoDe PET, 1999

Page 8: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Evidence Profile for PET

Diagnosticaccuracy

Technical performance

Healthimpact

Therapeuticimpact

Diagnosticimpact

Majority

Costeffectiveness

Eur J Rad, 1999

limited number a few (modeling)

Page 9: Cost-Effectiveness FDG-PET in Lung Cancer Staging

1) Decision-tree model construction

Decision Tree Analysis

Gambhir et al. JNM 1996

2) Medical literature survey

3) Calculation of expected cost & effectiveness

4) Sensitivity analysis

• evaluate each tree over variable range

• determine break-even point for variables

Page 10: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Decision Tree Model

StrategiesBx (-)

Surgery (+) Nodes

Surgery (-) Nodes

CT (+)

Bx (+)Op

Bx

CT

Surgery (+) Nodes

Surgery (-) Nodes

CT (-)

Op

PET

PET (-)

CT (-)

Surgery (-) Nodes

Surgery (+) Nodes

CT

Op

CT-only

PET+CT Surgery (+) Nodes

Surgery (-) Nodes

CT (+)

BxBx (+)

Bx (-) Op

Surgery (-) Nodes

Surgery (+) Nodes

Bx (+)PET (+)

Bx (-)

BxOp

CT

Page 11: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Unresectable rate 31 %

CT 예민도 67 %

CT 특이도 73 %

PET 예민도 90 %

PET 특이도 91 %

생검 morbitity 0.

007 yr

수술 morbitity 0.083 yr

PET 사망율 0.0000 % CT 사망율 0.0025 %

생검 사망율 0.3 %

수술 사망율 3.0 %

LE-resectable 7 yr

LE-unresectable 1 yr

Medical Literature Survey

Page 12: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Effectiveness = life expectancy (LE)

Calculation of Expected Cost & Effectiveness

Cost = medical expenditure

• CT cost = 700 $• PET cost = 1,000 $• Biopsy cost = 3,000 $• Surgery cost = 30,000 $

Declining exponential approximation of LE method

annual mortality of gen pop. + by dsLE =

1

( )

Page 13: Cost-Effectiveness FDG-PET in Lung Cancer Staging

RESULTS

• Average 1,154 $ savings per patient (25,634$ vs. 24,480$)

• No loss of LE (2.96 day gain)

Conservative CT+PET Strategy (A)

• Average 2,267 $ savings per patient (25,634 $ vs. 23,367 $)

• Failure to operate on 1.7% of resectable cases

Less conservative CT+PET Strategy (C)

• Average 1,154 $ savings per patient (25,634$ vs. 24,480$)

• No loss of LE (2.96 day gain)

Conservative CT+PET Strategy (A)

Page 14: Cost-Effectiveness FDG-PET in Lung Cancer Staging

26.2

25.8

25.4

25.0

24.6

24.2

0.300 0.475 0.650 0.825 1.000

PET Sensitivity

Exp

ecte

d V

alue

(th

ousa

nd $

)

CT

CT + PET

Threshold Values SENS = 0.48 EV = $25,600

Sensitivity Analysis

Page 15: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Threshold Values

SPEC = 0.12

EV = $25,600

25.7

25.5

25.3

25.1

24.9

24.7

24.5

24.3

0.100 0.325 0.550 0.775 1.000

PET Specificity

Exp

ecte

d V

alue

(th

ousa

nd $

)

CT CT + PET

Sensitivity Analysis

Page 16: Cost-Effectiveness FDG-PET in Lung Cancer Staging

1.00

0.94

0.88

0.82

0.76

0.700.15 0.19 0.23 0.27 0.31 0.35

Prevalance

PE

T S

pec

ific

ity

CT

CT + PET

Two-way sensitivity analysis

Page 17: Cost-Effectiveness FDG-PET in Lung Cancer Staging

5,000

4,100

3,200

2,300

1,400

5005,000 14,000 23,000 32,000 41,000 50,000

Surgery Cost ($)

PE

T C

ost

($)

CT

CT + PET

Two-way sensitivity analysis

Page 18: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Scott et al. Ann Thorac Surg, 1998

Variables different from 1st study

PET 예민도 90 %

PET 특이도 91 %

PET 예민도 , CT+ 89 %PET 예민도 . CT- 76 %

PET 특이도 , CT+ 81 % PET 특이도 , CT- 97 %

CT cost 700 $ PET cost 1,000 $ Biopsy cost 3,000 $ Surgery cost 30,000 $

378 $ 2,000 $ 4,360 $18,500 $

Page 19: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Decision Tree Model

Strategies

CT alone

Bx (-)

Surgery (+) Nodes

Surgery (-) Nodes

CT (+)

Bx (+)

Surgery (+) Nodes

Surgery (-) Nodes

CT (-)

CT

Bx

Op

Op

CT

CT (-)

PET (-)

Surgery (-) Nodes

Surgery (+) Nodes

PET

Op

Surgery (+) Nodes

Surgery (-) Nodes

PET (+)

BxBx (+)

Bx (-) Op

Surgery (-) Nodes

Surgery (+) Nodes

Bx (+)CT (+)

Bx (-)

BxOp

PET

(CT+PET)

Page 20: Cost-Effectiveness FDG-PET in Lung Cancer Staging

Strategies

CT+PET *

CT (-) PET

PET (-)Surgery (-) Nodes

Surgery (+) Nodes

Op

Surgery (+) Nodes

Surgery (-) Nodes

PET (+)

Op

Bx (+)

Bx (-)

Surgery (-) Nodes

Surgery (+) Nodes

Bx (+)

CT (+)

Bx (-)

CT

Bx

Op

Page 21: Cost-Effectiveness FDG-PET in Lung Cancer Staging

RESULTS

Strategy CT alone (CT+PET) CT+PET*

Cost 16,743 $ 17,708 $ 16,920 $

LE 4.921 y 4.928 y 4.928 y

ICER ( - ) 137,857 25,286

* Incremental cost-effectiveness ratio (ICER)

(LEX - LE A)ICER =

(CostX-CostA)

Page 22: Cost-Effectiveness FDG-PET in Lung Cancer Staging

100

80

60

40

20

0

-20

-40

1400 1600 1800 2000 2200

Cost PET ($)

ICE

R (

$1,0

00/Y

r)

BCD

Sensitivity Analysis

Page 23: Cost-Effectiveness FDG-PET in Lung Cancer Staging

100

80

60

40

20

0

-20

-40

0.25 0.3 0.35 0.4

Prevalence

ICE

R (

$1,0

00/Y

r)

BCD

Sensitivity Analysis

Page 24: Cost-Effectiveness FDG-PET in Lung Cancer Staging

PET distant metastasis of NSCLC

Lewis (1994)

Bury(1996)

Rigo(1997)

Valk(1996)

Tx plan change in 41%Surgery avoided in 18%

N-stage change in 21%M-stage change in 10%

M stage change in 14%

Metastasis detected in 11%Confirm metastasis in 7%Exclude metastasis in 16%

n = 34

n = 61

n = 39

n = 99

Page 25: Cost-Effectiveness FDG-PET in Lung Cancer Staging

• PET 700 $

• Surgery, benign 8,323 $

• Surgery, malign 16,377 $

FDG PET Cost-Effectiveness in Japan

Analysis Method

Cost

• 7.3 mo LE increase effect

• ICER = 20 만 Yen / yr.pt

Results of CT+PET strategy

• Decision-tree analysis

Kosuda et al. Chest, 2000

Page 26: Cost-Effectiveness FDG-PET in Lung Cancer Staging

FDG PET Cost-Effectiveness in ROK ?

Unresectable rate 31 %

CT 예민도 67 %

CT 특이도 73 %

PET 예민도 90 %

PET 특이도 91 %

수술 사망율 3.0 %

CT cost

PET cost

Biopsy cost

Surgery cost

700 $

1,000 $

3,000 $

30,000 $

Variables and Cost ?

Management policies ?

Health Care Environment ?

SNU 83%73%

Ajou

76%