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Cost-Effectiveness FDG-PET in Lung Cancer Staging.

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Presentation on theme: "Cost-Effectiveness FDG-PET in Lung Cancer Staging."— Presentation transcript:

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2 Cost-Effectiveness FDG-PET in Lung Cancer Staging

3  Small cell cancer20~25%  Squamous ca30~35%  Adenocarcinoma30~35%  Large cell ca15~20% 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

4 Staging of NSCLC I A T 1 N 0 M I B T 2 N 0 M II A T 1 N 1 M II B T 2 N 1 M 0 T 3 N 0 M 0 III A T 3 N 1 M 0 T 1~3 N 2 M 0 III B T 1~4 N 3 M 0 T 4 N 0~2 M 0 IV any M 1 1 – Stage Definition 5Y surv(%) Resectability 38~39 23~25 1~8 + N3N3 N2N2 + +

5 Peribronchial LN Ipsilateral hilar LN Intrapulmonary LN N1 Ipsilateral mediastinal LN Subcarinal LN N2 Contralateral mediastinal Contralateral hilar LN Supraclavicular LN N3

6 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

7 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

8 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

9 Evidence Profile for PET Diagnostic accuracy Technical performance Health impact Therapeutic impact Diagnostic impact Majority Cost effectiveness Eur J Rad, 1999 limited numbera few (modeling)

10 1) Decision-tree model construction Decision Tree Analysis Gambhir et al. JNM ) Medical literature survey 3) Calculation of expected cost & effectiveness 4) Sensitivity analysis evaluate each tree over variable range determine break-even point for variables

11  Decision Tree Model Strategies  Bx (-) 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 (+)      Bx Bx (+) Bx (-) Op Surgery (-) Nodes Surgery (+) Nodes Bx (+) PET (+) Bx (-)      Bx Op CT 

12 Unresectable rate 31 % CT 예민도 67 % CT 특이도 73 % PET 예민도 90 % PET 특이도 91 % 생검 morbitity yr 수술 morbitity yr PET 사망율 % CT 사망율 % 생검 사망율 0.3 % 수술 사망율 3.0 % LE-resectable 7 yr LE-unresectable 1 yr Medical Literature Survey

13 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 ds LE = 1 ( )

14 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)

15 PET Sensitivity Expected Value (thousand $)  CT  CT + PET               Threshold Values SENS = 0.48 EV = $25,600 Sensitivity Analysis

16 Threshold Values SPEC = 0.12 EV = $25,              PET Specificity Expected Value (thousand $)  CT  CT + PET  Sensitivity Analysis

17 Prevalance PET Specificity CT CT + PET Two-way sensitivity analysis

18 5,000 4,100 3,200 2,300 1, ,000 14,000 23,000 32,000 41,000 50,000 Surgery Cost ($) PET Cost ($) CT CT + PET Two-way sensitivity analysis

19 Scott et al. Ann Thorac Surg, 1998 Variables different from 1 st 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 $

20 Decision Tree Model Strategies CT alone  Bx (-) Surgery (+) Nodes Surgery (-) Nodes    CT (+) Bx (+)   Surgery (+) Nodes Surgery (-) Nodes CT (-)    CT Bx Op  CT  CT (-) PET (-) Surgery (-) Nodes Surgery (+) Nodes    PET Op Surgery (+) Nodes Surgery (-) Nodes PET (+)      Bx Bx (+) Bx (-) Op Surgery (-) Nodes Surgery (+) Nodes Bx (+) CT (+) Bx (-)      Bx Op PET  (CT+PET)

21 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 

22 RESULTS StrategyCT alone(CT+PET)CT+PET* Cost16,743 $ 17,708 $16,920 $ LE4.921 y y4.928 y ICER ( - ) 137,857 25,286 * Incremental cost-effectiveness ratio (ICER) (LE X - LE A ) ICER = (Cost X -Cost A )

23 Cost PET ($) ICER ($1,000/Yr) BCDBCD Sensitivity Analysis

24 Prevalence ICER ($1,000/Yr) BCDBCD Sensitivity Analysis

25 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

26 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

27 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%  


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