Evaluating PET–CT in routine surveillance and follow‐up after treatment for cervical cancer: a cost‐effectiveness analysis

Abstract

Objective To undertake a cost-effectiveness analysis that compares positron emission tomography -computed tomography (PET-CT) imaging plus standard practice with standard practice alone in the diagnosis of recurrent or persistent cervical cancer during routine surveillance and follow-up of women who have previously been diagnosed and treated.Design Model-based economic evaluation using data from a systematic review, supplemented with data from other sources, and taking a UK National Health Service (NHS) perspective.Setting Secondary Care in England.Population Women at least 3 months after the completion of treatment, with either recurrent or persistent cervical cancer.Methods A state transition (Markov) model was developed using TREEAGE PRO 2011. The structure of the model was informed by the reviews of the trials and clinical input. In the model, two diagnostic strategies were examined. A one-way sensitivity analysis, probabilistic sensitivity analysis, and a value of information analysis were also carried out.Main outcome measures Cost-effectiveness based on incremental cost per quality-adjusted life year (QALY).Results Adding PET-CT to the current treatment strategy of clinical examination and scanning [magnetic resonance imaging (MRI) and/or CT scan] during the routine surveillance and follow-up of women with recurrent or persistent cervical cancer is significantly more costly, with only a minimal increase in effectiveness. The incremental cost-effectiveness ratio (ICER) for the strategy of PET-CT as an adjunct to the standard treatment strategy that included clinical examination, MRI, and/or CT scan, compared with the usual treatment alone, was over £1 million per QALY. ConclusionThe results of the current analysis suggest that use of PET-CT in the diagnosis of recurrent or persistent cervical cancer is not cost-effective. Current guidelines recommending imaging using PET-CT as a diagnostic or surveillance tool need to be reconsidered in light of these results. This study did not specifically investigate the use of PET-CT in women with symptoms and radiological suspicion of recurrence where exenteration was considered. More research in that specific area is required.

Economic evaluations of follow-up strategies for cancer survivors: a systematic review and quality appraisal of the literature

“…Twenty-four articles did not report any discount rate for future costs and health outcomes. Five papers [18,20,23,38,40] applied a discount rate to costs only (i.e., either 3.0 or 3.5%). In nine articles, costs and effects were discounted at the same rate (i.e., 3.0% in eight cases, 5.0% in one).…”

“…In five cases [18,22,27,32,45], one or more diagnostic tests were added to routine surveillance (e.g., PET-CT imaging plus standard practice). All these papers concluded that a less-intensive follow-up program was clinically and economically justified for a variety of malignancies (i.e., breast, cervical and colorectal cancer and melanoma).…”

Clinical Indications and Impact on Management: Fourth and Subsequent Posttherapy Follow-up 18F-FDG PET/CT Scans in Oncology Patients

“…Performing routine surveillance 18 F-FDG PET/CT was not cost-effective and had no significant impact on management. The minimal impact on management could be due to lead time bias, and if those patients could get a clinical follow-up, the tumor recurrence would become symptomatic or detected using conventional imaging in several weeks (10,(34)(35)(36).…”

Radiotherapy response evaluation using FDG PET-CT—established and emerging applications

“…60% predicted disease-free survival and 49 another study reported a limited NPV with 21% of patients with CMR on post-treatment FDG PET-CT developing disease recurrence during the median 28-month follow-up, 53 with tumour size and stage acting as predictors for recurrent disease. Furthermore, a systematic review suggests that although more accurate than MRI, PET-CT is less cost-effective in post-treatment surveillance 54 than standard follow-up. Therefore, whilst PET-CT offers promise in post-treatment assessment of cervical cancer, its potential to add value to the treatment pathway remains to be fully realized.…”