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

Economic Evaluation of Long-Term Survivorship Care for Cancer Patients in OECD Countries: A Systematic Review for Decision-Makers

Long-term cancer survivorship care is a crucial component of an efficient healthcare system. For numerous reasons, there has been an increase in the number of cancer survivors; therefore, healthcare decision-makers are tasked with balancing a finite budget with a strong demand for services. Decision-makers require clear and pragmatic interpretation of results to inform resource allocation decisions. For these reasons, the impact and importance of economic evidence are increasing. The aim of the current study was to conduct a systematic review of economic evaluations of long-term cancer survivorship care in Organization for Economic Co-operation and Development (OECD) member countries and to assess the usefulness of economic evidence for decision-makers. A systematic review of electronic databases, including MEDLINE, PubMed, PsycINFO and others, was conducted. The reporting quality of the included studies was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Each included study’s usefulness for decision-makers was assessed using an adapted version of a previously published approach. Overall, 3597 studies were screened, and of the 235 studies assessed for eligibility, 34 satisfied the pre-determined inclusion criteria. We found that the majority of the included studies had limited value for informing healthcare decision-making and conclude that this represents an ongoing issue in the field. We recommend that authors explicitly include a policy statement as part of their presentation of results.

Diagnostic Strategies for Recurrent Cervical Cancer: A Cohort Study

Objective

The effectiveness of various strategies for the post-treatment monitoring of cervical cancer is unclear. This pilot study was conducted to explore recurrence patterns in and diagnostic strategies for patients with uterine cervical cancer who were meticulously followed using a customized monitoring plan.

Methods

The epidemiological and clinical data of patients with recurrent cervical cancer treated from March 2012 to April 2018 at a tertiary teaching hospital were retrospectively collected. The diagnostic methods and their reliability were compared across patients with various clinicopathological characteristics and were associated with survival outcomes.

Results

Two hundred sixty-four patients with recurrent cervical cancer were included in the study, among which recurrence occurred in the first three years after the last primary treatment in 214 patients (81.06%). Half of the recurrence events (50.76%) occurred only within the pelvic cavity, and most lesions (78.41%) were multiple in nature. Among all recurrent cases, approximately half were diagnosed based on clinical manifestations (n=117, 44.32%), followed by imaging examinations (n=76, 28.79%), serum tumor markers (n=34, 12.88%), physical examinations (n=33, 12.50%) and cervical cytology with or without high-risk human papillomavirus (hrHPV) testing (n=4, 1.52%). The reliability of the diagnostic methods was affected by the stage (p<0.001), primary treatment regimen (p=0.001), disease-free survival (p=0.022), recurrence site (p=0.002) and number of recurrence sites (p=0.001). Primary imaging methods (sonography and chest X-ray) were not inferior to secondary imaging methods (computed tomography, magnetic resonance imaging and positron emission tomography-computed tomography) in the detection of recurrence. The chest X-ray examination only detected three cases (1.14%) of recurrence. Patients assessed with various diagnostic strategies had similar progression-free and overall survival outcomes.

Conclusions

A meticulous evaluation of clinical manifestations might allow recurrence to be discovered in a timely manner in most patients with cervical cancer. Specific diagnostic methods for revealing recurrence were not associated with the survival outcomes.

Follow-Up 18F-FDG PET/CT versus Contrast-Enhanced CT after Ablation of Liver Metastases of Colorectal Carcinoma-A Cost-Effectiveness Analysis

PURPOSE

After a percutaneous ablation of colorectal liver metastases (CRLM), follow-up investigations to evaluate potential tumor recurrence are necessary. The aim of this study was to analyze whether a combined 18F-Fluordesoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) scan is cost-effective compared to a contrast-enhanced computed tomography (CE-CT) scan for detecting local tumor progression.

MATERIALS AND METHODS

A decision model based on Markov simulations that estimated lifetime costs and quality-adjusted life years (QALYs) was developed. Model input parameters were obtained from the recent literature. Deterministic sensitivity analysis of diagnostic parameters based on a Monte-Carlo simulation with 30,000 iterations was performed. The willingness-to-pay (WTP) was set to $100,000/QALY.

RESULTS

In the base-case scenario, CE-CT resulted in total costs of $28,625.08 and an efficacy of 0.755 QALYs, whereas 18F-FDG PET/CT resulted in total costs of $29,239.97 with an efficacy of 0.767. Therefore, the corresponding incremental cost-effectiveness ratio (ICER) of 18F-FDG PET/CT was $50,338.96 per QALY indicating cost-effectiveness based on the WTP threshold set above. The results were stable in deterministic and probabilistic sensitivity analyses.

CONCLUSION

Based on our model, 18F-FDG PET/CT can be considered as a cost-effective imaging alternative for follow-up investigations after percutaneous ablation of colorectal liver metastases.

Benefits of positron emission tomography scans for the evaluation of radiotherapy

The assessment of tumour response during and after radiotherapy determines the subsequent management of patients (adaptation of treatment plan, monitoring, adjuvant treatment, rescue treatment or palliative care). In addition to its role in extension assessment and therapeutic planning, positron emission tomography combined with computed tomography provides useful functional information for the evaluation of tumour response. The objective of this article is to review published data on positron emission tomography combined with computed tomography as a tool for evaluating external radiotherapy for cancers. Data on positron emission tomography combined with computed tomography scans acquired at different times (during, after initial and after definitive [chemo-]radiotherapy, during post-treatment follow-up) in solid tumours (lung, head and neck, cervix, oesophagus, prostate and rectum) were collected and analysed. Recent recommendations of the National Comprehensive Cancer Network are also reported. Positron emission tomography combined with computed tomography with (¹⁸F)-labelled fluorodeoxyglucose has a well-established role in clinical routine after chemoradiotherapy for locally advanced head and neck cancers, particularly to limit the number of neck lymph node dissection. This imaging modality also has a place for the evaluation of initial chemoradiotherapy of oesophageal cancer, including the detection of distant metastases, and for the post-therapeutic evaluation of cervical cancer. Several radiotracers for positron emission tomography combined with computed tomography, such as choline, are also recommended for patients with prostate cancer with biochemical failure. (¹⁸F)-fluorodeoxyglucose positron emission tomography combined with computed tomography is optional in many other circumstances and its clinical benefits, possibly in combination with MRI, to assess response to radiotherapy remain a very active area of research.

Improving Value-Based Care Education in a Fellowship by Incorporating ACGME Competencies

BACKGROUND

Most value-based care educational interventions teach knowledge of cost but fail to recognize the interrelatedness of the Accreditation Council for Graduate Medical Education (ACGME) competencies of medical knowledge, patient care, practice-based learning and improvement, and systems-based practice.

OBJECTIVE

We analyzed the impact on clinical decision-making of an educational curriculum that incorporated the spectrum of ACGME competencies.

METHODS

Five didactic sessions for a gynecologic oncology fellowship were modified to incorporate cost- and value-based care considerations for each clinical topic addressed. After discussion, the group of fellows identified 1 high-value and 5 low-value practices to target for improvement. The fellows then undertook a chart audit of clinical decisions occurring for patients seen in the outpatient clinics. The frequency of low- and high-value practices was compared before and after the educational intervention.

RESULTS

A total of 126 patients with a cervical cancer diagnosis were seen by participants in the outpatient setting during the entire observation period. After the intervention, the occurrence of 3 identified low-value practices was reduced by 13% to 33%, demonstrating modest effect sizes (effect size ϕ = 0.2-0.3). One high-value practice (smoking cessation counseling) increased 100% after a fellow-initiated quality improvement project was undertaken. Two low-value practices, including routine surveillance imaging, remained unchanged.

CONCLUSIONS

Overlaying value-based concepts in didactic conference teaching resulted in measurable changes in decision-making behavior. Engaging learners in a subsequent, focused quality practice review served as a vital part of their educational experience and allowed us to assess learner competency in its practical application.

Implementation of diagnostic resources for cancer in developing countries: a focus on PET/CT

Positron emission tomography in conjunction with computed tomography (PET/CT) is a relatively novel diagnostic tool which has been proven to be clinically useful in various neoplasms. Currently, only a handful of developing countries have PET/CT capabilities, and in those that do units are mostly located in large urban areas, which limits their availability. The implementation of PET/CT units in low-and-middle income countries is hampered by their high cost, the difficulties associated with their operation, and the limited availability of trained personnel. Furthermore, although the clinical appropriateness of PET/CT is well defined in many scenarios, little is known about its cost-effectiveness, particularly in settings with limited resources. Here, we provide a brief overview of the challenges associated with the implementation of PET/CT in resource-limited settings, including some examples of available data on its cost-effectiveness.

18F-FDG PET/CT in locally advanced cervical cancer: A review

Cervical cancer is the second most common gynecological cancer worldwide. In locally advanced cervical cancer, ¹⁸F-FDG PET/CT has become important in the initial staging, particularly in the detection of nodal and distant metastasis, aspects with treatment implications and prognostic value. The aims of this study were to review the role of ¹⁸F-FDG PET/CT in uterine cervical cancer, according to the guidelines of the main scientific institutions (FIGO, NCCN, SEGO, SEOM, ESGO, and ESMO) and its diagnostic accuracy compared to conventional radiological techniques, as well as to review the acquisition protocol and its utility in radiotherapy planning, response assessment and detection of recurrence.

The cost-effectiveness of follow-up strategies after cancer treatment: a systematic literature review

INTRODUCTION

The cost of treatment and follow-up of cancer patients in the UK is substantial. In a budget-constrained system such as the NHS, it is necessary to consider the cost-effectiveness of the range of management strategies at different points on cancer patients' care pathways to ensure that they provide adequate value for money.

SOURCES OF DATA

We conducted a systematic literature review to explore the cost-effectiveness of follow-up strategies of patients previously treated for cancer with the aim of informing UK policy. All papers that were considered to be economic evaluations in the subject areas described above were extracted.

AREAS OF AGREEMENT

The existing literature suggests that intensive follow-up of patients with colorectal disease is likely to be cost-effective, but the opposite holds for breast cancer.

AREAS OF CONTROVERSY

Interventions and strategies for follow-up in cancer patients were variable across type of cancer and setting. Drawing general conclusions about the cost-effectiveness of these interventions/strategies is difficult.

GROWING POINTS

The search identified 2036 references but applying inclusion/exclusion criteria a total of 44 articles were included in the analysis. Breast cancer was the most common (n = 11) cancer type followed by colorectal (n = 10) cancer. In general, there were relatively few studies of cost-effectiveness of follow-up that could influence UK guidance. Where there was evidence, in the most part, NICE guidance broadly reflected this evidence.

AREAS TIMELY TO DEVELOP RESEARCH

In terms of future research around the timing, frequency and composition of follow-ups, this is dependent on the type of cancer being considered. Nevertheless, across most cancers, the possibility of remote follow-up (or testing) by health professionals other than hospital consultants in other settings appears to warrant further work.

[18F]-2-Fluoro-2-Deoxy-D-glucose-PET Assessment of Cervical Cancer

This article provides an overview of PET in cervical cancer, primarily with regard to the use of ¹⁸F-2-fluoro-2-deoxy-d-glucose-PET/computed tomography. A brief discussion of upcoming technologies, such as PET/MR imaging, is presented.

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

Radiation therapy is a common component of curative cancer treatment. However, there is a significant incidence of treatment failure. In these cases, salvage surgical options are sometimes appropriate. Accurate assessment of response and early recognition of treatment success or failure is therefore critical to guide treatment decisions and impacts on survival and the morbidity of treatment. Traditionally, treatment response has depended upon the anatomical measurement of disease. However, this may not correlate well with the presence of disease, especially after radiotherapy. Combined positron emission tomography (PET) and CT imaging employs radioactive tracers to identify molecular characteristics of tissues. PET imaging exploits the fact that malignancies have characteristic molecular profiles which differ compared with surrounding tissues. The complementary anatomical and functional information facilitates accurate non-invasive assessment of surrogate biomarkers of disease activity.

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

The Centers for Medicare and Medicaid Services coverage includes 3 posttherapy ¹⁸F-FDG PET/CT scans per patient and per tumor type. Any additional follow-up ¹⁸F-FDG PET/CT scans will be reimbursed at the discretion of a local Medicare administrator, if deemed medically necessary. This study aimed to investigate common clinical indications for performing a fourth or additional follow-up ¹⁸F-FDG PET/CT scans that could affect the management of patients. Methods: This was a retrospective institutional review of 433 oncology patients (203 men; mean age, 55 y), including a total of 1,659 fourth or subsequent follow-up PET/CT scans after completion of primary treatment. Twelve indications for performing a fourth or subsequent follow-up PET/CT scan were determined, and the impact of each of the 12 indications on patients' management was evaluated. Results: The primary tumors were breast cancer (92 patients, 426 scans), non-Hodgkin lymphoma (77 patients, 208 scans), Hodgkin disease (41 patients, 182 scans), colorectal cancer (70 patients, 286 scans), melanoma (69 patients, 271 scans), and lung cancer (84 patients, 286 scans). The indications were categorized in 4 groups: PET/CT for diagnosis of tumor recurrence (303/1,659, 18.3%), PET/CT before starting therapy for tumor recurrence (64/1,659, 3.9%), PET/CT to assess therapy response for tumor recurrence (507/1,659, 30.6%), and follow-up PET/CT after completion of treatment for tumor recurrence (785/1,659, 47.3%). Overall, fourth and subsequent follow-up ¹⁸F-FDG PET/CT scans resulted in change in management in 31.6% of the scans (356 of 1,128) when the scans were obtained for medical necessities (indications 1-11), and in 5.6% of the scans (30/531) when the scans were obtained without any medical necessity (indication 12). Conclusion: The fourth and subsequent PET/CT scans obtained after completion of primary treatment led to a change in management in 31.6% of the scans when acquired for appropriate clinical reasons. Performing follow-up PET/CT without appropriate medical reason had a low impact on patients' management and should be avoided.

Does Routine Posttreatment PET/CT Add Value to the Care of Women With Locally Advanced Cervical Cancer?

Objectives

The aim of this study was to determine the necessary reduction in recurrence rate that would make postchemoradiation positron emission tomography (PET)/computed tomography (CT) to direct completion hysterectomy for locally advanced cervical cancer (LACC) cost-effective.

Methods

A decision model evaluated costs and recurrence rates of 2 posttreatment surveillance strategies in LACC: (1) routine surveillance without PET/CT and (2) PET/CT after 3 months to triage to completion hysterectomy. Incremental cost-effectiveness ratios were expressed in dollars per additional cancer recurrence avoided. Model parameters included expected rates of recurrence using each strategy, true- and false-positive rates of posttreatment PET/CT, and major complications of completion hysterectomy. From published data, we modeled an LACC baseline recurrence rate of 32%, PET/CT false-positive rate of 33%, and false-negative rate of 19%. We assumed that PET/CT revealed persistent local cervical cancer in 16% and progressive or distant disease in 6%. Costs of PET/CT, hysterectomy, and treatment for recurrence were based on Medicare reimbursements. A 50% salvage rate with hysterectomy was assumed and varied in sensitivity analysis.

Results

Routine use of PET/CT to direct completion hysterectomy was associated with a higher average cost ($16,579 vs $15,450) and a lower recurrence rate (26% vs 32%). The incremental cost-effectiveness ratio of PET was $20,761 per recurrence prevented. When the probability of recurrence after hysterectomy dropped to 25% or less, PET/CT was a dominant strategy.

Conclusions

Routine use of PET/CT to determine which patients may benefit from a completion hysterectomy after chemoradiation for LACC has the potential to be highly cost-effective.

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

The aim of this study was to review and critically assess the health economics literature on post-treatment follow-up for adult cancer survivors. A systematic search was performed using PubMed, EMBASE and the Cochrane Library. The Consolidated Health Economic Evaluation Reporting Standards checklist was adopted to assess the quality of the included studies. Thirty-nine articles met the eligibility criteria. Around two thirds of the studies addressed the most common cancers (i.e., breast, colorectal, cervical and lung); 21 were based on a single clinical study, while the rest were modeling papers. All types of economic evaluations were represented other than cost-benefit analysis. The overall quality was generally high with an average proportion of 74% of checklist criteria fulfilled. The cost-effectiveness results supported the current trend towards less intensive, primary care-based and risk-adapted follow-up schemes.

Economic Considerations on the Follow-Up Practice in Gynecologic Cancers: Few Lights and Many Shadows From a Literature Review

Objective

The aim of this review was to analyze the existing literature on the cost of follow-up in gynecology oncology.

Methods/materials

We performed a literature search in Medline and NHS CRD (University of Oxford) databases. Research strings were mainly based on MESH terms referring to economic studies and to neoplasms follow-up/aftercare and cancer recurrences. Two independent searches were performed for ovarian neoplasm and uterine neoplasm. Some studies were also identified among the references of the selected articles. Potentially relevant studies were identified based on the title and abstract by 2 independent readers.

Results

Finally, the reviewing process selected 2 studies on gynecologic cancers in general, including uterine and ovarian cancers, 3 specific on ovarian cancer, 7 on endometrium, and 9 on cervix. The identified economic literature on economic evaluation of gynecologic cancer follow-up procedures showed to be based on weak evidence of effectiveness and to lack formal methodological approaches. In general, such literature is quite recent, relies on small sample observational studies, and suffers from a lack of financial support.

Conclusions

There are few available lights in economic considerations on gynecologic cancer follow-up, represented by all the published studies, and many shadows that require to be clarified by properly designed randomized trials including cost-effectiveness analysis.

Cost-effectiveness of PET and PET/computed tomography: a systematic review

The development of clinical diagnostic procedures comprises early-phase and late-phase studies to elucidate diagnostic accuracy and patient outcome. Economic assessments of new diagnostic procedures compared with established work-ups indicate additional cost for 1 additional unit of effectiveness measure by means of incremental cost-effectiveness ratios when considering the replacement of the standard regimen by a new diagnostic procedure. This article discusses economic assessments of PET and PET/computed tomography reported until mid-July 2014. Forty-seven studies on cancer and noncancer indications were identified but, because of the widely varying scope of the analyses, a substantial amount of work remains to be done.

Evaluating PET-CT in the detection and management of recurrent cervical cancer: systematic reviews of diagnostic accuracy and subjective elicitation

BACKGROUND

Positron emission tomography-computed tomography (PET-CT) is recommended to triage women for exenterative surgery and surveillance after treatment for advanced cervical cancer.

OBJECTIVE

To evaluate diagnostic accuracy of additional whole body PET-CT compared with CT/magnetic resonance imaging (MRI) alone in women with suspected recurrent/persistent cervical cancer and in asymptomatic women as surveillance.

DESIGN

Systematic reviews. Subjective elicitation to supplement diagnostic information.

SEARCH STRATEGY/SELECTION CRITERIA/DATA COLLECTION AND ANALYSIS

Searches of electronic databases were performed to June 2013. Studies in women with suspected recurrent/persistent cervical cancer and in asymptomatic women undergoing follow up with sufficient numeric data were included. We calculated sensitivity, specificity and corresponding 95% confidence intervals. Meta-analyses employed a bivariate model that included a random-effects term for between-study variations (CT studies) and univariate random effects meta-analyses (PET-CT studies) for sensitivity and specificity separately.

SUBJECTIVE ELICITATION

Prevalence of recurrence and the accuracy of imaging elicited using the allocation of points technique. Coherence of elicited subjective probabilities with estimates in the literature examined.

RESULTS

We identified 15 relevant studies; none directly compared additional PET-CT with MRI or CT separately. Most CT and MRI studies used older protocols and the majority did not distinguish between asymptomatic and symptomatic women. Meta-analysis of nine PET-CT studies in mostly symptomatic women showed sensitivity of 94.8 (95% CI 91.2-96.9), and specificity of 86.9% (95% CI 82.2-90.5). The summary estimate of the sensitivity of CT for detection of recurrence was 89.64% (95% CI 81.59-94.41) and specificity was 76% (95% CI 43.68-92.82). Meta-analysis for MRI test accuracy studies was not possible because of clinical heterogeneity. The sensitivity and specificity of MRI in pelvic recurrence varied between 82 and 100% and between 78 and 100%, respectively. Formal statistical comparisons of the accuracy of index tests were not possible. Subjective elicitation provided estimates comparable to the literature. Subjective estimates of the increase in accuracy from the addition of PET-CT were less than elicited increases required to justify the use in PET-CT for surveillance.

CONCLUSION

Evidence to support additional PET-CT is scarce, of average quality and does not distinguish between application for surveillance and diagnosis. Guidelines recommending PET-CT in recurrent cervical cancer need to be reconsidered in the light of the existing evidence base.