Abstract
PurposeRectal cancer is one of the most frequent causes of cancer-related morbidity and mortality in the world. Correct identification of the TNM state in primary staging of rectal cancer has critical implications on patient management. Initial evaluations revealed a high sensitivity and specificity for whole-body PET/MRI in the detection of metastases allowing for metastasis-directed therapy regimens. Nevertheless, its cost-effectiveness compared with that of standard-of-care imaging (SCI) using pelvic MRI + chest and abdominopelvic CT is yet to be investigated. Therefore, the aim of this study was to analyze the cost-effectiveness of whole-body 18F FDG PET/MRI as an alternative imaging method to standard diagnostic workup for initial staging of rectal cancer.MethodsFor estimation of quality-adjusted life years (QALYs) and lifetime costs of diagnostic modalities, a decision model including whole-body 18F FDG PET/MRI with a hepatocyte-specific contrast agent and pelvic MRI + chest and abdominopelvic CT was created based on Markov simulations. For obtaining model input parameters, review of recent literature was performed. Willingness to pay (WTP) was set to $100,000/QALY. Deterministic sensitivity analysis of diagnostic parameters and costs was applied, and probabilistic sensitivity was determined using Monte Carlo modeling.ResultsIn the base-case scenario, the strategy whole-body 18F FDG PET/MRI resulted in total costs of $52,186 whereas total costs of SCI were at $51,672. Whole-body 18F FDG PET/MRI resulted in an expected effectiveness of 3.542 QALYs versus 3.535 QALYs for SCI. This resulted in an incremental cost-effectiveness ratio of $70,291 per QALY for PET/MRI. Thus, from an economic point of view, whole-body 18F FDG PET/MRI was identified as an adequate diagnostic alternative to SCI with high robustness of results to variation of input parameters.ConclusionBased on the results of the analysis, use of whole-body 18F FDG PET/MRI was identified as a feasible diagnostic strategy for initial staging of rectal cancer from a cost-effectiveness perspective.
Highlights
Material and methodsCancer is one of the most important causes of morbidity and mortality in the world, with rectal cancer being within the top 3 most cancers especially in developed countries [1].Current therapeutic standards include a wide range of chemo- and radiotherapy, surgery, and local ablative therapies with several therapeutic options even in metastasized disease [2, 3].Besides adequate diagnosis of local tumor extent, early detection of metastases is important as metastasis-directed therapy regimens including ablation or resection of metastases can be efficient in increasing patient overall survival [3,4,5]
The aim of this study is to determine the cost-effectiveness of 18F FDG positron emission tomography (PET)/magnetic resonance imaging (MRI) at initial staging of rectal cancer as compared with that of standard-of-care imaging (SCI) using pelvic MRI with chest and abdominopelvic computed tomography (CT)
Pre-test probability of initial M1 tumor Expected age at diagnostic procedure Assumed willingness to pay per quality-adjusted life years (QALYs) Discount rate Markov model time horizon Diagnostic test performances MRI sensitivity for M1 MRI specificity for M1 CT + pelvic MRI sensitivity for M1 CT + pelvic MRI specificity for M1 Costs PET/MRI CT whole body Pelvic MRI Biopsy Probability of biopsy Ablation Costs M0 yearly
Summary
Current therapeutic standards include a wide range of chemo- and radiotherapy, surgery, and local ablative therapies with several therapeutic options even in metastasized disease [2, 3]. Besides adequate diagnosis of local tumor extent, early detection of metastases is important as metastasis-directed therapy regimens including ablation or resection of metastases can be efficient in increasing patient overall survival [3,4,5]. Positron emission tomography (PET)/MRI provided high sensitivity and high specificity for detection of metastases, avoiding the need for additional diagnostic procedures [7, 8]. In a study recently published by Mayerhoefer et al, PET/MRI with various clinical tracers was shown to have only slightly higher overall costs when compared with PET/CT in a range of cancer entities [9]. The increasing number of PET/MRI installations and possible implementation of PET/ MRI in clinical practice bear the potential of lowering the cost per examination
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