Abstract
BackgroundThe optimal posttreatment surveillance strategy for nasopharyngeal carcinoma (NPC) remains unclear. Circulating cell-free Epstein-Barr virus (cfEBV) DNA has been recognized as a promising biomarker to facilitate early detection of NPC recurrence. Therefore, we aim to determine whether integrating circulating cfEBV DNA into NPC follow-up is cost-effective.MethodsFor each stage of asymptomatic nonmetastatic NPC patients after complete remission to primary NPC treatment, we developed a Markov model to compare the cost-effectiveness of the following surveillance strategies: routine follow-up strategy, i.e., (1) routine clinical physical examination; routine imaging strategies, including (2) routine magnetic resonance imaging plus computed tomography plus bone scintigraphy (MRI + CT + BS); and (3) routine 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT); cfEBV DNA-guided imaging strategies, including (4) cfEBV DNA-guided MRI + CT + BS and (5) cfEBV DNA-guided PET/CT. Clinical probabilities, utilities, and costs were derived from published studies or databases. Sensitivity analyses were performed.ResultsFor all disease stages, cfEBV DNA-guided imaging strategies demonstrated similar survival benefits but were considerably more economical than routine imaging strategies. They only required approximately one quarter of the number of imaging studies compared with routine imaging strategies to detect one recurrence. Specifically, cfEBV DNA-guided MRI + CT + BS was most cost-effective for stage II (incremental cost-effectiveness ratio [ICER] $57,308/quality-adjusted life-year [QALY]) and stage III ($46,860/QALY) patients, while cfEBV DNA-guided PET/CT was most cost-effective for stage IV patients ($62,269/QALY). However, routine follow-up was adequate for stage I patients due to their low recurrence risk.ConclusionsThe cfEBV DNA-guided imaging strategies are effective and cost-effective follow-up methods in NPC. These liquid biopsy-based strategies offer evidence-based, stage-specific surveillance modalities for clinicians and reduce disease burden for patients.
Highlights
The optimal posttreatment surveillance strategy for nasopharyngeal carcinoma (NPC) remains unclear
Model construction We developed a Markov decision-analytic model to evaluate the cost-effectiveness of five surveillance strategies in NPC (Additional file 1: Fig. S1A): routine follow-up strategy, i.e., (1) routine clinical physical examination; routine imaging strategies, including (2) routine magnetic resonance imaging (MRI) plus computed tomography (CT) plus bone scintigraphy (MRI + CT + Bone scintigraphy (BS)); and (3) routine 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT); cell-free Epstein-Barr virus (cfEBV) DNA-guided imaging strategies, including (4) cfEBV DNA-guided MRI + CT + BS; and (5) cfEBV DNA-guided PET/CT
The incremental cost-effectiveness ratio (ICER) of routine imaging strategies compared with cfEBV DNA-guided PET/CT went far beyond the willingness-to-pay threshold, ranging from $262,724/qualityadjusted life-year (QALY) in stage IV to $3,882,176/ QALY in stage I, and the routine MRI + CT + BS was dominated by cfEBV DNA-guided PET/CT in stage IV (Additional file 1: Table S5)
Summary
The optimal posttreatment surveillance strategy for nasopharyngeal carcinoma (NPC) remains unclear. Circulating cell-free Epstein-Barr virus (cfEBV) DNA has been recognized as a promising biomarker to facilitate early detection of NPC recurrence. We aim to determine whether integrating circulating cfEBV DNA into NPC follow-up is cost-effective. More than 20% of patients with nonmetastatic nasopharyngeal carcinoma (NPC) will experience disease recurrence despite aggressive primary treatment, contributing largely to treatment failure and death [1, 2]. The posttreatment surveillance is essential to detect recurrence timely when the tumor burden is minimal, which would maximize the efficacy of salvage treatment and might improve survival [3,4,5,6]. It is imperative to identify a follow-up strategy that can detect recurrence in a timely and cost-effective manner
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