cost-effectiveness fdg-pet in lung cancer staging
TRANSCRIPT
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Cost-Effectiveness
FDG-PET in
Lung Cancer Staging
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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
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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
++
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Peribronchial LN
Ipsilateral hilar LN
Intrapulmonary LN
N1
Ipsilateral mediastinal LN
Subcarinal LN
N2
Contralateral mediastinal
Contralateral hilar LN
Supraclavicular LN
N3
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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
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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
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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
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Evidence Profile for PET
Diagnosticaccuracy
Technical performance
Healthimpact
Therapeuticimpact
Diagnosticimpact
Majority
Costeffectiveness
Eur J Rad, 1999
limited number a few (modeling)
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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
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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
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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
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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
( )
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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)
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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
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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
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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
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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
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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 $
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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)
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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
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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)
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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
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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
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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
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• 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
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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%