MRI and 18F-FET PET for Multimodal Treatment Monitoring in Patients with Brain Metastases: A Cost-Effectiveness Analysis.

PET using the radiolabeled amino acid O-(2-[18F]fluoroethyl)-l-tyrosine (18F-FET) has been shown to be of value for treatment monitoring in patients with brain metastases after multimodal therapy, especially in clinical situations with equivocal MRI findings. As medical procedures must be justified socioeconomically, we determined the effectiveness and cost-effectiveness of 18F-FET PET for treatment monitoring of multimodal therapy, including checkpoint inhibitors, targeted therapies, radiotherapy, and combinations thereof in patients with brain metastases secondary to melanoma or non-small cell lung cancer. Methods: We analyzed already-published clinical data and calculated the associated costs from the German statutory health insurance system perspective. Two clinical scenarios were considered: decision tree model 1 determined the effectiveness of 18F-FET PET alone for identifying treatment-related changes, that is, the probability of correctly identifying patients with treatment-related changes confirmed by neuropathology or clinicoradiographically using the Response Assessment in Neuro-Oncology criteria for immunotherapy. The resulting cost-effectiveness ratio showed the cost for each correctly identified patient with treatment-related changes in whom MRI findings remained inconclusive. Decision tree model 2 calculated the effectiveness of both 18F-FET PET and MRI, that is, the probability of correctly identifying nonresponders to treatment. The incremental cost-effectiveness ratio was calculated to determine cost-effectiveness, that is, the cost for each additionally identified nonresponder by 18F-FET PET who would have remained undetected by MRI. One-way deterministic and probabilistic sensitivity analyses tested the robustness of the results. Results: 18F-FET PET identified 94% of patients with treatment-related changes, resulting in €1,664.23 (€1.00 = $1.08 at time of writing) for each correctly identified patient. Nonresponders were correctly identified in 60% by MRI and in 80% by 18F-FET PET, resulting in €3,292.67 and €3,915.83 for each correctly identified nonresponder by MRI and 18F-FET PET, respectively. The cost to correctly identify 1 additional nonresponder by 18F-FET PET, who would have remained unidentified by MRI, was €5,785.30. Conclusion: Given the considerable annual cost of multimodal therapy, the integration of 18F-FET PET can potentially improve patient care while reducing costs.

A cost-utility analysis of 18F-fluorocholine-positron emission tomography imaging for localizing primary hyperparathyroidism in the United States.

BACKGROUND: Primary hyperparathyroidism historically necessitated bilateral neck exploration to remove abnormal parathyroid tissue. Improved localization allows for focused parathyroidectomy with lower complication risks. Recently, positron emission tomography using radiolabeled 18F-fluorocholine demonstrated high accuracy in detecting these lesions, but its cost-effectiveness has not been studied in the United States. METHODS: A decision tree modeled patients who underwent parathyroidectomy for primary hyperparathyroidism using single preoperative localization modalities: (1) positron emission tomography using radiolabeled 18F-fluorocholine, (2) 4-dimensional computed tomography, (3) ultrasound, and (4) sestamibi single photon emission computed tomography (SPECT). All patients underwent either focused parathyroidectomy versus bilateral neck exploration, with associated cost ($) and clinical outcomes measured in quality-adjusted life-years gained. Model parameters were informed by literature review and Medicare costs. Incremental cost-utility ratios were calculated in US dollars/quality-adjusted life-years gained, with a willingness-to-pay threshold set at $100,000/quality-adjusted life-year. One-way, 2-way, and threshold sensitivity analyses were performed. RESULTS: Positron emission tomography using radiolabeled 18F-fluorocholine gained the most quality-adjusted life-years (23.9) and was the costliest ($2,096), with a total treatment cost of $11,245 or $470/quality-adjusted life-year gained. Sestamibi single photon emission computed tomography and ultrasound were dominated strategies. Compared with 4-dimentional computed tomography, the incremental cost-utility ratio for positron emission tomography using radiolabeled 18F-fluorocholine was $91,066/quality-adjusted life-year gained in our base case analysis, which was below the willingness-to-pay threshold. In 1-way sensitivity analysis, the incremental cost-utility ratio was sensitive to test accuracy, positron emission tomography using radiolabeled 18F-fluorocholine price, postoperative complication probabilities, proportion of bilateral neck exploration patients needing overnight hospitalization, and life expectancy. CONCLUSION: Our model elucidates scenarios in which positron emission tomography using radiolabeled 18F-fluorocholine can potentially be a cost-effective imaging option for primary hyperparathyroidism in the United States. Further investigation is needed to determine the maximal cost-effectiveness for positron emission tomography using radiolabeled 18F-fluorocholine in selected populations.

Early stopping in clinical PET studies: How to reduce expense and exposure.

Clinical positron emission tomography (PET) research is costly and entails exposing participants to radioactivity. Researchers should therefore aim to include just the number of subjects needed to fulfill the purpose of the study. In this tutorial we show how to apply sequential Bayes Factor testing in order to stop the recruitment of subjects in a clinical PET study as soon as enough data have been collected to make a conclusion. By using simulations, we demonstrate that it is possible to stop a study early, while keeping the number of erroneous conclusions low. We then apply sequential Bayes Factor testing to a real PET data set and show that it is possible to obtain support in favor of an effect while simultaneously reducing the sample size with 30%. Using this procedure allows researchers to reduce expense and radioactivity exposure for a range of effect sizes relevant for PET research.

Postoperative Surveillance in Older Adults With T1N0M0 Low-risk Papillary Thyroid Cancer.

BACKGROUND: The frequency and cost of postoperative surveillance for older adults (>65 y) with T1N0M0 low-risk papillary thyroid cancer (PTC) have not been well studied. METHODS: Using the SEER-Medicare (2006-2013) database, frequency and cost of surveillance concordant with American Thyroid Association (ATA) guidelines (defined as an office visit, ≥1 thyroglobulin measurement, and ultrasound 6- to 24-month postoperatively) were analyzed for the overall cohort of single-surgery T1N0M0 low-risk PTC, stratified by lobectomy versus total thyroidectomy. RESULTS: Majority of 2097 patients in the study were white (86.7%) and female (77.5%). Median age and tumor size were 72 y (interquartile range 68-76) and 0.6 cm (interquartile range 0.3-1.1 cm), respectively; 72.9% of patients underwent total thyroidectomy. Approximately 77.5% of patients had a postoperative surveillance visit; however, only 15.9% of patients received ATA-concordant surveillance. Patients who underwent total thyroidectomy as compared with lobectomy were more likely to undergo surveillance testing, thyroglobulin (61.7% versus 24.8%) and ultrasound (37.5% versus 29.2%) (all P < 0.01), and receive ATA-concordant surveillance (18.5% versus 9.0%, P < 0.001). Total surveillance cost during the study period was $621,099. Diagnostic radioactive iodine, ablation, and advanced imaging (such as positron emission tomography scans) accounted for 55.5% of costs ($344,692), whereas ATA-concordant care accounted for 44.5% of costs. After multivariate adjustment, patients who underwent total thyroidectomy as compared with lobectomy were twice as likely to receive ATA-concordant surveillance (adjusted odds ratio 2.0, 95% confidence interval: 1.5-2.8, P < 0.001). CONCLUSIONS: Majority of older adults with T1N0M0 low-risk PTC do not receive ATA-concordant surveillance; discordant care was costly. Total thyroidectomy was the strongest predictor of receiving ATA-concordant care.

Evaluating determinants of receipt of molecular imaging in biochemical recurrent prostate cancer.

BACKGROUND: Molecular imaging with novel radiotracers is changing the treatment landscape in prostate cancer (PCa). Currently, standard of care includes either conventional and molecular imaging at time of biochemical recurrence (BCR). This study evaluated the determinants of and cost associated with utilization of molecular imaging for BCR PCa. METHODS: This is a retrospective observational cohort study among men with BCR PCa from June 2018 to May 2019. Multivariate logistic regression models were employed to analyze the primary outcome: receipt of molecular imaging (e.g. Fluciclovine PET and Prostate Specific Membrane Antigen PET) as part of diagnostic work-up for BCR PCa. Multivariate linear regression models were used to analyze the secondary outcome: overall healthcare cost within a 1-year time frame. RESULTS: The study sample included 234 patients; 79.1% White, 2.1% Black, 8.5% Asian/Pacific Islander, and 10.3% Other. The majority were 55 years or older (97.9%) and publicly insured (74.8%). Analysis indicated a one-unit reduction in PSA is associated with 1.3 times higher likelihood of receiving molecular imaging (p < 0.01). Analysis found that privately insured patients were associated with approximately $500,000 more in hospital reimbursement (p < 0.01) as compared to the publicly insured. Additionally, a one-unit increase in PSA is associated with $6254 increase in hospital reimbursement or an increase in total payments by 2.1% (p < 0.05). CONCLUSIONS: Higher PSA was associated with lower likelihood for molecular imaging and higher cost in a one-year time frame. Higher cost was also associated with private insurance, but there was no clear relationship between insurance type and imaging type.

Surgery alone for papillary thyroid microcarcinoma is less costly and more effective than long term active surveillance.

BACKGROUND: Papillary thyroid microcarcinoma is a subtype of thyroid cancer that may be managed with active surveillance rather than immediate surgery. Active surveillance decreases complication rates and may decrease health care costs. This study aims to analyze complication rates of thyroid surgery, papillary thyroid microcarcinoma recurrence, and survival rates. Additionally, the costs of surgery versus hypothetic active surveillance for papillary thyroid microcarcinoma are compared in an Australian cohort. METHODS: Papillary thyroid microcarcinoma patients were included from a prospectively collected surgical cohort of patients treated for papillary thyroid cancer between 1985 and 2017. The primary outcomes were the complications of thyroid surgery, recurrence-free survival, overall survival, and cost of surgical treatment and active surveillance. RESULTS: In a total of 349 patients with papillary microcarcinoma with a median age of 48 years (range, 18-90 years), the permanent operative complications rate was 3.7%. Postoperative radioactive iodine did not decrease recurrence-free survival (P = .3). The total cost of surgical treatment was $10,226 Australian dollars, whereas hypothetic active surveillance was at a yearly cost of $756 Australian dollars. Estimated cost of surgical papillary thyroid microcarcinoma treatment was equivalent to the cost of 16.2 years of active surveillance. CONCLUSION: Surgery may have a long-term economic advantage for younger Australian patients with papillary thyroid microcarcinoma who are likely to require more than 16.2 years of follow-up in an active surveillance scheme.

18F-Choline PET/mpMRI for Detection of Clinically Significant Prostate Cancer: Part 2. Cost-Effectiveness Analysis.

The objective of this study was to evaluate the cost-effectiveness of 18F-choline PET/multiparametric MRI (mpMRI) versus mpMRI alone for the detection of primary prostate cancer with a Gleason score of greater than or equal to 3 + 4 in men with elevated prostate-specific antigen levels. Methods: A Markov model of prostate cancer onset and progression was used to estimate the health and economic consequences of 18F-choline PET/mpMRI for the detection of primary prostate cancer with a Gleason score of greater than or equal to 3 + 4 in men with elevated prostate-specific antigen levels. Multiple simultaneous hybrid 18F-choline PET/mpMRI strategies were evaluated using Likert or Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) scoring; the first was biopsy for Likert 5 mpMRI lesions or Likert 3-4 lesions with 18F-choline target-to-background ratios of greater than or equal to 1.58, and the second was biopsy for PI-RADSv2 5 mpMRI lesions or PI-RADSv2 3-4 mpMRI lesions with 18F-choline target-to-background ratios of greater than or equal to 1.58. These strategies were compared with universal standard biopsy, mpMRI alone with biopsy only for PI-RADSv2 3-5 lesions, and mpMRI alone with biopsy only for Likert 4-5 lesions. For each mpMRI strategy, either no biopsy or standard biopsy could be performed after negative mpMRI results were obtained. Deaths averted, quality-adjusted life years (QALYs), cost, and incremental cost-effectiveness ratios were estimated for each strategy. Results: When the results of 18F-choline PET/mpMRI were negative, performing a standard biopsy was more expensive and had lower QALYs than performing no biopsy. The best screening strategy among those considered in this study performed hybrid 18F-choline PET/mpMRI with Likert scoring on men with elevated PSA, performed combined biopsy (targeted biopsy and standard 12-core biopsy) for men with positive imaging results, and no biopsy for men with negative imaging results ($22,706/QALY gained relative to mpMRI alone); this strategy reduced the number of biopsies by 35% in comparison to mpMRI alone. When the same policies were compared using PI-RADSv2 instead of Likert scoring, hybrid 18F-choline PET/mpMRI cost $46,867/QALY gained relative to mpMRI alone. In a threshold analysis, the best strategy among those considered remained cost-effective when the sensitivity and specificity of PET/mpMRI and combined biopsy (targeted biopsy and standard 12-core biopsy) were simultaneously reduced by 20 percentage points. Conclusion:18F-choline PET/mpMRI for the detection of primary prostate cancer with a Gleason score of greater than or equal to 3 + 4 is cost-effective and can reduce the number of unneeded biopsies in comparison to mpMRI alone.

Integrating molecular nuclear imaging in clinical research to improve anticancer therapy.

Effective patient selection before or early during treatment is important to increasing the therapeutic benefits of anticancer treatments. This selection process is often predicated on biomarkers, predominantly biospecimen biomarkers derived from blood or tumour tissue; however, such biomarkers provide limited information about the true extent of disease or about the characteristics of different, potentially heterogeneous tumours present in an individual patient. Molecular imaging can also produce quantitative outputs; such imaging biomarkers can help to fill these knowledge gaps by providing complementary information on tumour characteristics, including heterogeneity and the microenvironment, as well as on pharmacokinetic parameters, drug-target engagement and responses to treatment. This integrative approach could therefore streamline biomarker and drug development, although a range of issues need to be overcome in order to enable a broader use of molecular imaging in clinical trials. In this Perspective article, we outline the multistage process of developing novel molecular imaging biomarkers. We discuss the challenges that have restricted the use of molecular imaging in clinical oncology research to date and outline future opportunities in this area.

Positron emission tomography costs less to patients than conventional screening for malignancy in dermatomyositis.

BACKGROUND: Dermatomyositis (DM) is associated with malignancy and interstitial lung disease. Many malignancies associated with DM occur in organs not routinely screened by national guidelines; thus, best screening practices are still debated. Positron emission tomography (PET) has been suggested as a single study alternative to more complex screening panels and may also be valuable in detecting interstitial lung disease progression. Criticisms of PET screening exams have focused on cost and radiation exposure. OBJECTIVE: To compare the cost of PET and its variants to conventional malignancy screening panels, and to review concerns regarding radiation exposure in PET. METHODS: Four variants of PET and PET-CT were included in the study. The conventional screening panel was defined as CT of the abdomen and pelvis without contrast, CT of the thorax without contrast, CEA, CA 19.9, PSA (men), mammography (women), transvaginal ultrasound (women), cytopathology (women), and CA 125 (women). The MarketScan® Commercial Claims and Encounters database, a collection of private insurance claims data from 53 million Americans, was queried for every instance of each test from 2005 to 2014 and the mean inflation-adjusted cost of each was recorded. The mean total cost to insurance companies and the mean out-of-pocket costs to patients for PET variants were compared to the costs for conventional panels. Additionally, the cost of pulmonary function tests (PFT) from the same period was evaluated. RESULTS: From 2005-2014, the mean inflation-adjusted costs of PET have trended downward, but the mean cost of PET-CT have trended upward. The mean total cost to insurance companies for PET-CT whole body was $730.70 and $537.62 greater than the cost of conventional panels for men and women, respectively. The out-of-pocket patient costs for PET-CT whole body was $109.82 and $111.33 less than the cost of conventional panels for men and women, respectively. The mean total cost of PFT was $205.02. CONCLUSIONS: The cost of PET-CT whole body was greater than conventional panels for insurance companies, but patient out-of-pocket costs were lower. PET-CT may also have added value in detecting and monitoring interstitial lung disease progression in DM patients. More data are needed on the efficacy of PET-CT in detecting malignancy in DM patients; however, the cost difference is less than expected, suggesting the single scan could be a reasonable alternative to the conventional screening panel in some patients.

IntegoTM infusion system: cost effectiveness analysis focusing on dosimetry, sterility and management.

BACKGROUND: Healthcare providers across Europe are facing an ever-growing demand in clinical PET referrals. Currently, it is estimated that the administration of the PET tracer accounts for approximately 40% of the unitary PET procedure reimbursement (uPETr). Although the cost of PET/CT is highly dependent on the radiopharmaceutical cost itself, little is known about the economic impact of the utilized administration method and the repercussions on staff radiation exposure. Our objective was to evaluate the cost-effectiveness of automatic injection/fractionation system Intego™ (Bayer HealthCare, MEDRAD Europe, Netherlands) for istaff radiation exposure reduction and to validate its use with 18F-choline (FCH). METHODS: In order to validate Intego™ use with FCH we analyzed sterility, radioactivity fractionation accuracy and radiation protection for staff. We analyzed Intego™ impact on examination costs and its impact on organization efficiency. A cost-effectiveness analysis (CEA) was estimated as the incremental cost to reduce staff radiationexposure. RESULTS: According to our data, Intego™ ensures both sterility and accuracy of FCH doses' activity, reducing, at the same time, the exposure to radiation either whole body and at the extremities (94% and 75% respectively for the technicians and complete reduction for physicians). Intego™'s variable unit costs are higher than the SA (respectively 1.8% and 0.4% of PET reimbursement), while staff costs are significantly higher with SA (respectively 0.27% and 1.57% of unitary PET reimbursement [uPETr]). In our simulation, based on a 2,450 PET yearly output, the differential costs were slightly higher by using Intego™™ (+ 14%). The incremental cost-effectiveness ratio (ICER) was equal to 1.1, i.e. the healthcare provider pays an additional cost of 0.38% of uPETr to obtain a significant reduction of staff radiation exposure (-4.5 µS). CONCLUSIONS: Intego™, for its favorable results in terms of cost effectiveness, could be a useful tool in a nuclear medicine department, limiting the staff radiation exposure.

The impact of global budget on the diffusion of innovations: the example of positron emission tomography in Taiwan.

BACKGROUND: The essence of global budget is to set a cap on the total national health insurance expenditure for a year, which is one form of prospective payment systems. It has always been argued that prospective payment, such as global budgeting, will deter the development of high-tech services in the healthcare industry. The objectives of this study are to explore the impact of global budgeting on the diffusion of high tech equipment in terms of utilization by using Positron Emission Tomography (PET) as an example. METHODS: The study population is the hospitals in Taiwan. We tried to compare the diffusion patterns of Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and PET scanners among these hospitals by analyzing the National Health Insurance (NHI) Database from 1997 to 2010. RESULTS: From 2004 to 2010, 79,380 PET scans in total were performed under the NHI scheme. By the year 2010, the annual reimbursed scans have reached 19,700. The volume curve of cumulative PET services resembles an S diffusion curve with the R2 at 0.95. The results indicated the growth of cumulative PET service volume does correspond with the innovation diffusion model. The cumulative utilizations of CT, MRI and PET demonstrate good correlation with no significant difference in their growth rates. CONCLUSIONS: Therefore, we can infer that even though PET was reimbursed after the implementation of global budgeting, its diffusion was not deterred by this cost containment measure when compared with CT and MRI in the same time span after the inauguration of the NHI.

18F-Sodium Fluoride PET/CT and PET/MR Imaging of Bone and Joint Disorders.

18F-sodium fluoride (18F-NaF) PET/CT provides high sensitivity and specificity for the assessment of bone and joint diseases. It is able to accurately differentiate malignant from benign bone lesions, especially when using dynamic quantitative approaches. Its high-quality, clinical accuracy, and high feasibility for patient management and greater availability of PET/CT scanners as well as decreasing trend of the cost of radiotracer all indicate the need to consider the use of 18F-NaF PET/CT as standard bone imaging, particularly in malignant diseases of the skeleton.

The Impact of the Choosing Wisely Campaign in Urology.

OBJECTIVE: To determine if 3 of the Canadian Urological Association's Choosing Wisely recommendations (released in 2013-2014) related to urologic care altered physician and patient behavior. METHODS: Administrative data from Ontario, Canada between 2008 and 2017 was used. We identified 3 cohorts: First, we determined how many men >66 years of age had a serum testosterone level before starting testosterone therapy. Second, we determined how many boys undergoing an orchiopexy underwent abdominal imaging before their surgery. Third, we determined how many men with low risk prostate cancer underwent a Bone Scan after diagnosis. Piece-wise linear regression was used to evaluate for a significant change after Choosing Wisely. RESULTS: We identified 13,113 men who had their initial prescription for testosterone filled. Serum testosterone measurement increased over time, from approximately 43% to 68%. There were 9319 boys who underwent an orchiopexy. The use of pre-orchiopexy ultrasound was generally stable (approximately 55%). We identified 27,174 men with low risk prostate cancer. The use of bone scans after diagnosis decreased over time from approximately 24% to 20%. In all 3 of these groups, there was no significant change after Choosing Wisely (P = .74, P = .70, P = .72 respectively). CONCLUSION: In Ontario, there was no evidence of a significant change in 3 practice patterns that were featured in Choosing Wisely Urology recommendations. Further thought may be needed on how to translate these and future recommendations into behavior change.

Additional Clinical Value for PET/MRI in Oncology: Moving Beyond Simple Diagnosis.

Initial clinical research comparing the diagnostic performance of PET/MRI and PET/CT has largely shown equivalent diagnostic capabilities for these modalities in oncology. These uncertainties about the magnitude of diagnostic benefit are compounded by the considerable health economic challenges associated with clinical implementation. Therefore, there is a need to identify ways to extend the use of this technology beyond simple diagnosis so that PET/MRI can add sufficient clinical value beyond PET/CT or MRI alone and become a cost-effective imaging modality in clinical practice. A major advantage of PET/MRI over other imaging modalities is the ability to generate multiple quantitative images from a single examination. This article describes how a multiparametric PET/MRI approach not only can add clinical value through contributing to precision medicine but also can establish PET/MRI as a potentially cost-effective imaging modality in oncology.

Variation in the use of advanced imaging at the time of breast cancer diagnosis in a statewide registry.

BACKGROUND: Although national guidelines do not recommend extent of disease imaging for patients with newly diagnosed early stage breast cancer given that the harm outweighs the benefits, high rates of testing have been documented. The 2012 Choosing Wisely guidelines specifically addressed this issue. We examined the change over time in imaging use across a statewide collaborative, as well as the reasons for performing imaging and the impact on cost of care. METHODS: Clinicopathologic data and use of advanced imaging tests (positron emission tomography, computed tomography, and bone scan) were abstracted from the medical records of patients treated at 25 participating sites in the Michigan Breast Oncology Quality Initiative (MiBOQI). For patients diagnosed in 2014 and 2015, reasons for testing were abstracted from the medical record. RESULTS: Of the 34,078 patients diagnosed with stage 0-II breast cancer between 2008 and 2015 in MiBOQI, 6853 (20.1%) underwent testing with at least 1 imaging modality in the 90 days after diagnosis. There was considerable variability in rates of testing across the 25 sites for all stages of disease. Between 2008 and 2015, testing decreased over time for patients with stage 0-IIA disease (all P < .001) and remained stable for stage IIB disease (P = .10). This decrease in testing over time resulted in a cost savings, especially for patients with stage I disease. CONCLUSION: Use of advanced imaging at the time of diagnosis decreased over time in a large statewide collaborative. Additional interventions are warranted to further reduce rates of unnecessary imaging to improve quality of care for patients with breast cancer. Cancer 2017;123:2975-83. © 2017 American Cancer Society.

O-(2-18F-fluoroethyl)-L-tyrosine PET for evaluation of brain metastasis recurrence after radiotherapy: an effectiveness and cost-effectiveness analysis.

BACKGROUND: Conventional MRI is the standard method to diagnose recurrence of brain metastases after radiation. However, following radiation therapy, reactive transient blood-brain barrier alterations with consecutive contrast enhancement can mimic brain metastasis recurrence. Recent studies have suggested that O-(2-18F-fluoroethyl)-L-tyrosine (FET) PET improves the correct differentiation of brain metastasis recurrence from radiation injury. Based on published evidence and clinical expert opinion, we analyzed effectiveness and cost-effectiveness of the use of FET PET in addition to MRI compared with MRI alone for the diagnosis of recurrent brain metastases. METHODS: A decision-tree model was designed to compare the 2 diagnostic strategies from the perspective of the German Statutory Health Insurance (SHI) system. Effectiveness was defined as correct diagnosis of recurrent brain metastasis and was compared between FET PET with MRI and MRI alone. Costs were calculated for a baseline scenario and for a more expensive scenario. Robustness of the results was tested using sensitivity analyses. RESULTS: Compared with MRI alone, FET PET in combination with MRI increases the rate of correct diagnoses by 42% (number needed to diagnose of 3) with an incremental cost-effectiveness ratio of €2821 (baseline scenario) and €4014 (more expensive scenario) per correct diagnosis. The sensitivity analyses confirmed the robustness of the results. CONCLUSIONS: The model suggests that the additional use of FET PET with conventional MRI for the diagnosis of recurrent brain metastases may be cost-effective. Integration of FET PET has the potential to avoid overtreatment with corresponding costs as well as unnecessary side effects.

Outside the operating room: How a robotics program changed resource utilization on the inpatient Ward.

OBJECTIVE: To analyze the changes in the composition of the gynecologic oncology inpatient ward following the implementation of a robotic surgery program and its impact on inpatient resource utilization and costs. METHODS: Retrospective review of the medical charts of patients admitted onto the gynecologic oncology ward the year prior to and five years after the implementation of robotics. The following variables were collected: patient characteristics, hospitalization details (reason for admission and length of hospital stay), and resource utilization (number of hospitalization days, consultations, and imaging). RESULTS: Following the introduction of robotic surgery, there were more admissions for elective surgery yet these accounted for only 21% of the inpatient ward in terms of number of hospital days, compared to 36% prior to the robotic program. This coincided with a sharp increase in the overall number of patients operated on by a minimally invasive approach (15% to 76%, p<0.0001). The cost per surgical admission on the inpatient ward decreased by 59% ($9827 vs. $4058) in the robotics era. The robotics program contributed to a ward with higher proportion of patients with complex comorbidities (Charlson≥5: RR 1.06), Stage IV disease (RR 1.30), and recurrent disease (RR 1.99). CONCLUSION: Introduction of robotic surgery allowed for more patients to be treated surgically while simultaneously decreasing inpatient resource use. With more patients with non-surgical oncological issues and greater medical complexity, the gynecologic oncology ward functions more like a medical rather than surgical ward after the introduction of robotics, which has implications for hospital-wide resource planning.

Imaging tests in staging and surveillance of non-metastatic breast cancer: changes in routine clinical practice and cost implications.

BACKGROUND: Although guidelines do not recommend computerised tomography (CT), positron emission tomography (PET) or magnetic resonance imaging (MRI) for the staging or follow-up of asymptomatic patients with non-metastatic breast cancer, they are often requested in routine clinical practice. The aim of this study was to determine the staging and follow-up patterns, and relative costs in a large population of breast cancer patients living and treated in a Southern Italian region. METHODS: We analysed the clinical computerised information recorded by 567 primary-care physicians assisting about 650 000 inhabitants in the Campania region. Patients with non-metastatic breast cancer were identified and divided into calendar years from 2001 to 2010. The number of diagnostic tests prescribed per 100 patients (N/Pts) and the mean cost per patient was determined 3 months before diagnosis and up to 1 year after diagnosis. Costs are expressed in constant 2011 euros. RESULTS: We identified 4680 newly diagnosed cases of asymptomatic non-metastatic breast cancer. N/Pts increased significantly (P<0.0001) from 2001 to 2010. The mean number of prescribed mammograms, bone scans, abdominal ultrasound and chest X-rays ('routine tests'), and costs was unchanged. However, the number of CT, PET scans and MRI ('new tests')prescriptions almost quadrupled and the mean cost per patient related to these procedures significantly increased from [euro ]357 in 2001 to [euro ]830 in 2010 (P<0.0001). CONCLUSIONS: New test prescriptions and relative costs significantly and steadily increased throughout the study period. At present there is no evidence that the delivery of new tests to asymptomatic patients improves breast cancer outcome. Well-designed clinical trials are urgently needed to shed light on the impact of these tests on clinical outcome and overall survival.

Surveillance Scans in Lymphoma: Friend or Foe?

OPINION STATEMENT: Advancements in the treatment of lymphoma over the last few decades have allowed more patients to achieve a remission after the completion of therapy. Due to the improvement in response rates, methods to detect recurrence early and accurately during follow-up, especially in patients with potential curable aggressive lymphomas, are a key. Observation has always involved close clinical follow-up with the use of physical exams and routine labs, but rapid changes in technology have allowed CT scans, PET scans, and MRIs to become an integral part of managing patients with lymphoma. While the utility of scans in initial staging and immediately after completion of therapy is well established, the use of these imaging modalities for monitoring recurrence in lymphoma patients is still controversial. Patient advocacy groups and other regulatory committees have questioned the frequency and in some cases even the need for these tests in patients without evidence of active disease given the concern for radiation-associated health risks. Additionally, the extent to which this form of testing impacts the psyche of our patients is not completely known. Given the numerous questions raised about the benefits, safety, and cost-effectiveness of CT imaging, firm guidelines are needed at this time in standard practice and within our clinical trials to limit the use of surveillance imaging. Such efforts are expected to improve the utility of these scans in asymptomatic patients, reduce healthcare costs, and reduce patient exposure to radiation.

Cost-Utility of Video-Electroencephalography Monitoring Followed by Surgery in Adults with Drug-Resistant Focal Epilepsy in Thailand.

OBJECTIVES: This study assessed whether video-electroencephalography (VEEG) monitoring followed by surgery was cost-effective in adult patients with drug-resistant focal epilepsy under Thai health care context, as compared with continued medical treatment without VEEG. METHODS: The total cost (in Thai Baht, THB) and effectiveness (in quality-adjusted life years, QALYs) were estimated over a lifetime horizon, using a decision tree and a Markov model. Data on short-term surgical outcomes, direct health care costs, and utilities were collected from Thai patients in a specialized hospital. Long-term outcomes and relative effectiveness of the surgery over medical treatment were derived, using systematic reviews of published literature. RESULTS: Seizure-free rates at years 1 and 2 after surgery were 79.4% and 77.8%, respectively. Costs of VEEG and surgery plus 1-year follow-up care were 216,782 THB, of which the VEEG and other necessary investigations were the main cost drivers (42.8%). On the basis of societal perspective, the total cost over a 40-year horizon accrued to 1,168,679 THB for the VEEG option, 64,939 THB higher than that for no VEEG. The VEEG option contributed to an additional 1.50 QALYs over no VEEG, resulting in an incremental cost-effectiveness ratio of 43,251 THB (USD 1236) per 1 QALY gained. Changes in key parameters had a minimal impact on the incremental cost-effectiveness ratio. Accounting for uncertainty, there was an 84% probability that the VEEG option was cost-effective on the basis of Thailand's cost-effective threshold of 160,000 THB/QALY. CONCLUSIONS: For patients with drug-resistant epilepsy, VEEG monitoring followed by epilepsy surgery was cost-effective in Thailand. Therefore it should be recommended for health insurance coverage.