PET/CT for staging lung cancer: costly or cost-saving?

Abstract

Integrated functional and anatomical imaging using positron emission tomography (PET)/CT hybrid scanners has changed the diagnostic algorithm in non-small cell lung cancer (NSCLC). The accuracy for detection of lymph node and distant organ metastases is superior to separately performed PET or CT scanning and other invasive or noninvasive diagnostic tests [1]. There is also evidence that PET/CT is particularly effective if curative surgery is cancelled when PET/CT indicates advanced disease whereas conventional staging procedures suggest curable disease. Diagnostic effectiveness of PET/CT for staging NSCLC and differential diagnosis of solitary pulmonary nodules has been recently approved by many health care systems worldwide. Additional indications for cancer imaging which are recognized in the USA and several European countries include staging and restaging of oesophageal, colorectal and breast cancer, malignant lymphoma, melanoma and head and neck cancer [2]. Regarding these indications, a diagnostic effectiveness and superiority to conventional cancer imaging modalities has been demonstrated. However, if PET/CT is also cost-effective when integrated into routine diagnostic algorithms has never been demonstrated. In lung cancer, noninvasive imaging modalities contribute to only a small proportion of total health care costs (∼5–6%) [3]. However, given the limited resources of health care systems, evidence for economic efficiency of novel diagnostic tools or therapeutics will become more relevant in the near future. In this issue of the European Journal of Nuclear Medicine and Molecular Imaging, Sogaard et al. report on the costeffectiveness of PET/CT for staging NSCLC [4]. In a randomized clinical trial, PET/CT was performed in addition to the conventional staging procedures in 98 patients. In the control group consisting of 91 patients, conventional staging was performed without PET/CT. They have shown that implementation of PET/CT into the diagnostic algorithm of staging NSCLC is cost-effective. The incremental costeffectiveness ratio (ICER) was calculated to be 19,314 €, meaning that PET/CT is cost-effective if the provider’s willingness to pay is 50,000 € per avoided ‘futile’ thoracotomy. The incremental cost for adding PET/CT to the diagnostic workup was estimated to be as high as 3,927 €. A more detailed analysis of cancer-related and comorbidity-related costs indicated that in the PET/CT group unexpectedly high comorbidity-related costs were spent in four patients which were not adequately randomized between both groups. When these comorbidity-related costs are excluded from the analysis, PET/CT appears to be dominant over routine diagnostic workup, resulting in cost savings of 899 € per patient and savings of 4,495 € per avoided thoracotomy. In the same study collective, the authors recently assessed the effect of combined PET/CT imaging on preoperative staging of NSCLC [5]. The number of patients identified as having advanced disease is twice as high as compared to the conventional group and, subsequently, a significantly higher number of non-curative, thus, unnecessary surgical A. K. Buck (*) Dept. of Nuclear Medicine, Nuklearmedizinische Klinik und Poliklinik, Universitatsklinikum Wurzburg, Oberdurrbacherstr. 6, 97080 Wurzburg, Germany e-mail: andreas.buck@tum.de