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Comparing Noninvasive, Minimally Invasive, and Invasive Strategies in the Initial Mediastinal Staging of Non-small Cell Lung Cancer: A Cost-Effective Analysis FREE TO VIEW

Alex Balekian, MD; Michael Gould, MD
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University of Southern California, Los Angeles, CA

Chest. 2013;144(4_MeetingAbstracts):655A. doi:10.1378/chest.1704874
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SESSION TITLE: Lung Cancer Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: In non-small cell lung cancer (NSCLC), the mediastinum can be staged with positron emission tomography (PET) scanning, fine needle aspiration (FNA) via endobronchial ultrasound (EBUS) or endoscopic ultrasound (EUS), and surgical mediastinoscopy. We performed a cost-effectiveness analysis to determine the best initial staging step for a peripheral nodule proven to be NSCLC.

METHODS: Using TreeAge 8.0, we constructed a cost-effectiveness model from a payer standpoint. We populated the model using data from the published literature and Medicare through March 2013. We compared four mediastinal staging strategies: EBUS-EUS-FNA without surgical confirmation, EBUS-EUS-FNA with surgical confirmation, PET scan, and mediastinoscopy with EUS-FNA.

RESULTS: We assumed a 30% risk of mediastinal metastasis and sensitivities of 80% for EBUS-EUS-FNA, 86% for mediastinoscopy with EUS-FNA, and 90% for PET. The most cost-effective strategy was EBUS-EUS-FNA without surgical confirmation, followed by mediastinoscopy with EUS-FNA (incremental cost-effectiveness ratio [ICER] of $9,900 per life-year gained) and PET scan (ICER $64,264 per life-year gained). EBUS-EUS-FNA with surgical confirmation of a negative result was the least favorable strategy. The model was most sensitive to the prevalence of N2 disease in the cohort, as well as to the assumption that insurance reimbursement would occur to a single thoracic surgeon combining sequential procedures in a single encounter; however, a sensitivity analysis using a Monte Carlo simulation consistently favored invasive staging strategies. The mediastinoscopy with EUS-FNA staging strategy was consistently the most cost-effective with a willingness-to-pay threshold of only $20,000 to gain one life-year and 15% fewer unnecessary thoracotomies than EBUS-EUS-FNA without surgical confirmation of a negative result.

CONCLUSIONS: Invasive strategies are more cost-effective than non-invasive strategies in the initial step of medastinal staging of NSCLC. Although minimally-invasive strategies appear slightly more cost effective, a low threshold exists to adopt routine mediastinoscopy with EUS-FNA as the preferred staging strategy.

CLINICAL IMPLICATIONS: Non-invasive or minimally-invasive staging strategies, though attractive for patient convenience, increase costs without clearly gaining benefit. A single thoracic surgeon performing these procedures sequentially in a single encounter can expedite care and decrease costs.

DISCLOSURE: The following authors have nothing to disclose: Alex Balekian, Michael Gould

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