Non-small cell lung cancer (NSCLC) continues to have high incidence and mortality in the United States. Although surgical resection is theoretically curative for early stage disease, 5-year survival rates are not ideal, possibly due to inaccurate non-invasive staging.
Using TreeAge 8.0 software, we constructed a cost-effectiveness model from a payer standpoint. The existing literature was reviewed, including: recent ACCP guidelines for staging and treatment; meta-analyses for PET, mediastinoscopy, and endoscopic ultrasound (EUS); as well as Medicare reimbursement data for 2008. The model was constructed to include a non-invasive arm with routine PET followed by confirmatory mediastinoscopy in the event of a positive scan, or else lobectomy in the event of a negative scan. The invasive arm included routine mediastinoscopy plus EUS without routine PET, followed by lobectomy in the event of negative results.
Using the base-case patient with biopsy-proven NSCLC and 30% probability of N2 disease, the invasive arm cost $7,443 for an average life expectancy (LE) of 4.392 years, while the non-invasive arm cost $8,062 for average LE of 4.394 years, yielding a cost difference of $619 per patient. The incremental cost-effectiveness ratio for routine PET was $309,500 for each life-year gained. A sensitivity analysis that varied costs by 50% and N2 prevalence from 0% to 60% consistently favored the invasive strategy.
Routine mediastinoscopy plus EUS without the use of PET scan for the accurate staging of NSCLC is more cost-effective compared to a non-invasive approach. Most of the savings occur from eliminating unnecessary lung resections with post-surgical hospitalizations for occult mediastinal disease, as well as avoiding PET altogether in the entire cohort.
The invasive staging approach saves resources, avoids unnecessary lobectomies, and results in equivalent life-year outcomes in a time when emerging technologies are being evaluated for comparative effectiveness.
Alex Balekian, No Financial Disclosure Information; No Product/Research Disclosure Information