Economic Evaluations of Chimeric Antigen Receptor T-Cell Therapies for Hematologic and Solid Malignancies: A Systematic Review.

OBJECTIVES: This study aimed to systematically review evidence on the cost-effectiveness of chimeric antigen receptor T-cell (CAR-T) therapies for patients with cancer. METHODS: Electronic databases were searched in October 2022 and updated in September 2023. Systematic reviews, health technology assessments, and economic evaluations that compared costs and effects of CAR-T therapy in patients with cancer were included. Two reviewers independently screened studies, extracted data, synthesized results, and critically appraised studies using the Philips checklist. Cost data were presented in 2022 US dollars. RESULTS: Our search yielded 1809 records, 47 of which were included. Most of included studies were cost-utility analysis, published between 2018 and 2023, and conducted in the United States. Tisagenlecleucel, axicabtagene ciloleucel, idecabtagene vicleucel, ciltacabtagene autoleucel, lisocabtagene maraleucel, brexucabtagene autoleucel, and relmacabtagene autoleucel were compared with various standard of care chemotherapies. The incremental cost-effectiveness ratio (ICER) for CAR-T therapies ranged from $9424 to $4 124 105 per quality-adjusted life-year (QALY) in adults and from $20 784 to $243 177 per QALY in pediatric patients. Incremental cost-effectiveness ratios were found to improve over longer time horizons or when an earlier cure point was assumed. Most studies failed to meet the Philips checklist due to a lack of head-to-head comparisons and uncertainty surrounding CAR-T costs and curative effects. CONCLUSIONS: CAR-T therapies were more expensive and generated more QALYs than comparators, but their cost-effectiveness was uncertain and dependent on patient population, cancer type, and model assumptions. This highlights the need for more nuanced economic evaluations and continued research to better understand the value of CAR-T therapies in diverse patient populations.

Index hospital cost of adverse events following thoracic surgery: a systematic review of economic literature.

OBJECTIVES: Adverse events (AEs) following thoracic surgery place considerable strain on healthcare systems. A rigorous evaluation of the economic impact of thoracic surgical AEs remains lacking and is required to understand the value of money of formal quality improvement initiatives. Our objective was to conduct a systematic review of all available literature focused on specific cost of postoperative AEs following thoracic surgery. DESIGN: Systematic review of the economic literature was performed, following recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA SOURCES: An economic search filter developed by the Canadian Agency for Drugs and Technologies in Health was applied, and MEDLINE, Embase and The Cochrane Library were searched from inception to January 2022. ELIGIBILITY CRITERIA: We included English articles involving adult patients who underwent a thoracic surgical procedure with estimated costs of postoperative complications. Eligible study designs included comparative observational studies, randomised control trials, decision analytic or cost-prediction models, cost analyses, cost or burden of illness studies, economic evaluation studies and systematic reviews and/or meta-analyses of cost analyses and cost of illness studies. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened titles and abstracts in the first stage and full-text articles of included studies in the second stage. Disagreements during abstract and full-text screening stages were resolved via discussion until a consensus was reached. Studies were appraised for methodological quality using the Critical Appraisal Skills Program checklist. RESULTS: 3349 studies were identified: 20 met inclusion criteria. Most were conducted in the USA (12/20), evaluating AE impact on hospital expenditures (18/20). 68 procedure-specific AE mean costs were characterised (USD$). The most commonly described were anastomotic leak (mean:range) (USD$49 278:$6 176-$133 002) and pneumonia ($12 258:$2608-$34 591) following esophagectomy, and prolonged air leak ($2556:$571-$3573), respiratory failure ($19 062:$11 841-$37 812), empyema ($30 189:$23 784-$36 595), pneumonia ($15 362:$2542-$28 183), recurrent laryngeal nerve injury ($16 420:$4224-$28 616) and arrhythmia ($6835:$5833-$8659) following lobectomy. CONCLUSIONS: Hospital costs associated with AEs following thoracic surgery are substantial and varied. Quantifying costs of AEs enable future economic evaluation studies, which could help prioritising value-directed quality improvement to optimally improve outcomes and reduce costs.

Economic feasibility of a novel tool to assist extubation decision-making: an early health economic modeling.

OBJECTIVES: To estimate the minimum percent change in failed extubation to make a tool designed to reduce extubation failure (Extubation Advisor [EA]) economically viable. METHODS: We conducted an early return on investment (ROI) analysis using data from intubated intensive care unit (ICU) patients at a large Canadian tertiary care hospital. We obtained input parameters from the hospital database and published literature. We ran generalized linear models to estimate the attributable length of stay, total hospital cost, and time to subsequent extubation attempt following failure. We developed a Markov model to estimate the expected ROI and performed probabilistic sensitivity analyses to assess the robustness of findings. Costs were presented in 2020 Canadian dollars (C$). RESULTS: The model estimated a 1 percent reduction in failed extubation could save the hospital C$289 per intubated patient (95 percent CI: 197, 459). A large center seeing 2,500 intubated ICU patients per year could save C$723,124/year/percent reduction in failed extubation. At the current annual price of C$164,221, the EA tool must reduce extubation failure by at least 0.24 percent (95 percent CI: .14, .41) to make the tool cost-effective at our site. CONCLUSIONS: Clinical decision-support tools like the EA may play an important role in reducing healthcare costs by reducing the rate of extubation failure, a costly event in the ICU.

Costs of Next-Generation Sequencing Assays in Non-Small Cell Lung Cancer: A Micro-Costing Study.

Background: Next-generation sequencing (NGS) of tumor genomes has changed and improved cancer treatment over the past few decades. It can inform clinicians on the optimal therapeutic approach in many of the solid and hematologic cancers, including non-small lung cancer (NSCLC). Our study aimed to determine the costs of NGS assays for NSCLC diagnostics. Methods: We performed a micro-costing study of four NGS assays (Trusight Tumor 170 Kit (Illumina), Oncomine Focus (Thermo Fisher), QIAseq Targeted DNA Custom Panel and QIASeq Targeted RNAscan Custom Panel (Qiagen), and KAPA HyperPlus/SeqCap EZ (Roche)) at the StemCore Laboratories, the Ottawa Hospital, Canada. We used a time-and-motion approach to measure personnel time and a pre-defined questionnaire to collect resource utilization. The unit costs were based on market prices. The cost data were reported in 2019 Canadian dollars. Results: Based on a case throughput of 500 cases per year, the per-sample cost for TruSight Tumor 170 Kit, QIASeq Targeted DNA Custom Panel and QIASeq Targeted RNAscan Custom Panel, Oncomine Focus, and HyperPlus/SeqCap EZ were CAD 1778, CAD 599, CAD 1100 and CAD 1270, respectively. The key cost drivers were library preparation (34-60%) and sequencing (31-51%), followed by data analysis (6-13%) and administrative support (2-7%). Conclusions: Trusight Tumor 170 Kit was the most expensive NGS assay for NSCLC diagnostics; however, an economic evaluation is required to identify the most cost-effective NGS assay. Our study results could help inform decisions to select a robust platform for NSCLC diagnostics from fine needle aspirates, and future economic evaluations of the NGS platforms to guide treatment selections for NSCLC patients.

Outpatient parenteral antibiotic therapy (OPAT) and inpatient treatment strategies for emergency department patients with cellulitis: a cost analysis.

OBJECTIVES: Emergency department (ED) patients with cellulitis requiring intravenous antibiotics may be treated via outpatient parenteral antibiotic therapy (OPAT) as opposed to hospitalization. The primary objective was to compare healthcare costs for the following strategies: community intravenous antibiotics with referral to an OPAT clinic operated by infectious disease specialists ('OPAT clinic' strategy); community intravenous antibiotics with return to ED if necessary ('return to ED' strategy); and hospital admission. METHODS: Using a hospital administrative database, we conducted a cost analysis using patient-level data of adult cellulitis patients presenting to two tertiary care EDs and were treated with intravenous antibiotics in one of three ways: OPAT clinic strategy; return to ED strategy; and hospital admission. Costs were estimated from Canada's publicly funded health system perspective. The primary outcome was the mean total cost (2015 CAD) per patient for each treatment strategy. A generalized linear model was performed to adjust for baseline characteristics, including age, sex and comorbidities. RESULTS: A total of 808 patients met inclusion criteria: OPAT clinic strategy (N = 341); return to ED strategy (N = 228) and hospital admission (N = 239). The mean total cost of care for the treatment strategies were: OPAT clinic: $2170 (95% CI $1905-$2436); return to ED: $1493 (95 %CI $1264-$1722); and hospital admission: $10,145 (95% CI $8668-$11,622). Results from the regression analysis suggested that the OPAT clinic strategy was associated with a cost-saving of $7394 (95% CI $6154-$8633, p < 0.001) compared to hospital admission and an increased cost of $651 (95% CI $367-$935, p < 0.001) when compared to the return to ED approach. CONCLUSIONS: This is the first Canadian study that compares the cost of different OPAT strategies for cellulitis patients. While both OPAT strategies are safe and far less costly than hospital admission, our findings suggest that a dedicated OPAT clinic for patients with cellulitis is more expensive than the return to ED strategy.

RéSUMé: OBJECTIFS: Les patients des services d'urgence atteints de cellulite nécessitant des antibiotiques intraveineux peuvent être traités par une antibiothérapie parentérale ambulatoire (OPAT) plutôt que par une hospitalisation. L'objectif principal était de comparer les coûts des soins de santé pour les stratégies suivantes : antibiotiques intraveineux communautaires avec orientation vers une clinique OPAT gérée par des spécialistes des maladies infectieuses (stratégie "clinique OPAT") ; antibiotiques intraveineux communautaires avec retour aux urgences si nécessaire (stratégie de "retour aux urgences") ; et admission à l'hôpital. MéTHODES: À l'aide d'une base de données administratives hospitalières, nous avons effectué une analyse des coûts en utilisant les données relatives aux patients adultes atteints de cellulite se présentant à deux urgences de soins tertiaires et traités par antibiotiques intraveineux de l'une des trois manières suivantes : Stratégie de la clinique OPAT ; stratégie de retour aux urgences; et admission à l'hôpital. Les coûts ont été estimés du point de vue du système de santé public du Canada. Le principal résultat était le coût total moyen (2015 CAD) par patient pour chaque stratégie de traitement. Un modèle linéaire généralisé a été réalisé pour ajuster les caractéristiques de base, y compris l'âge, le sexe et les comorbidités. RéSULTATS : Au total, 808 patients répondaient aux critères d'inclusion : stratégie clinique OPAT (N = 341) ; stratégie de retour aux urgences (N = 228) et admission à l'hôpital (N = 239). Le coût total moyen des soins pour les stratégies de traitement était le suivant : Clinique OPAT: 2 170 $ (IC 95 %: 1 905 $­2 436 $) ; retour aux urgences : 1 493 $ (IC à 95 %: 1 264 $­1 722 $) ; et hospitalisation : 10 145 $ (IC à 95 %: 8 668 $­11 622 $). Les résultats de l'analyse de régression suggèrent que la stratégie de la clinique OPAT est associée à une économie de 7 394 $ (IC à 95 %: 6 154 $­8 633 $, p < 0,001) par rapport à l'admission à l'hôpital et à une augmentation des coûts de 651 $ (IC à 95 %: 367 $­935 $, p < 0,001) par rapport à l'approche du retour aux urgences. CONCLUSIONS : Il s'agit de la première étude canadienne qui compare le coût de différentes stratégies d'OPAT pour les patients atteints de cellulite. Si les deux stratégies OPAT sont sûres et bien moins coûteuses que l'admission à l'hôpital, nos résultats suggèrent qu'une clinique OPAT dédiée aux patients atteints de cellulite est plus coûteuse que la stratégie de retour aux urgences.

Optimal Timing of Allogeneic Stem Cell Transplantation for Primary Myelofibrosis.

Primary myelofibrosis (PMF) is a chronic myeloproliferative neoplasm characterized by cytopenias, splenomegaly, and risk of leukemic transformation. In light of newer therapies, such as ruxolitinib, that are not curative but improve quality of life, the timing of transplantation needs more in-depth analysis to determine which patients would benefit from an early versus a delayed transplantation strategy. Because prospective clinical trials are impractical for diseases with only one curative option, such as PMF, we developed a Markov cohort model to simulate the long-term disease trajectory in patients with PMF and predict the optimal timing of transplantation stratified by Dynamic International Prognostic Scoring System (DIPSS) risk. In this decision model, a hypothetical cohort of patients begins in the alive with PMF state and can transition monthly to other health states. Transition probabilities were acquired from published literature. We performed probabilistic analyses by jointly varying all model parameters over 1000 simulations. Irrespective of DIPSS risk, all patients with PMF benefited from transplantation with respect to life expectancy gained. Life expectancy gains from transplantation peaked at 9.7 months (95% confidence interval [CI], 9.5 to 9.9 months) from diagnosis in patients with high-risk disease and at 16.6 months (95% CI, 16.4 to 16.8 months) from diagnosis in patients with intermediate-2 disease. Patients with intermediate-1 risk had a delayed peak in net gain in life expectancy at 20.5 months (95% CI, 20.2 to 20.7 months). Patients with low-risk disease had a greater net gain in life expectancy the longer that transplantation was delayed; this trend plateaued at 29 to 45 months. Our modeling suggests that preparation for transplantation is indicated upfront for patients diagnosed with intermediate-2 risk and high-risk PMF, whereas this can be delayed for low-risk or intermediate-1 risk disease.

Audit feedback interventions to address high-risk prescriptions in long-term care homes: a costing study and return on investment analysis.

BACKGROUND: Audit and feedback is a common implementation strategy, but few studies describe its costs. 'MyPractice' is a province-wide audit and feedback initiative to improve prescribing in nursing homes. This study sought to estimate the costs of 'MyPractice' and assess whether the financial benefit of 'MyPractice' offsets those costs. METHODS: We conducted a costing study from the perspective of the Ontario government. Total cost of 'MyPractice' was calculated as the sum of the costs of producing and disseminating the reports (covering three report releases) which were obtained from Ontario Health staff interviews and document reviews. Return on investment (ROI) was calculated as the ratio of net cost-savings and the intervention cost. Cost savings were based on the effectiveness of 'MyPractice' derived from a published cohort study. Cost-savings attributable to 'MyPractice' were estimated from the changes in the rates of antipsychotics over time between physicians who signed up and viewed the reports and those who did not sign up to the reports. RESULTS: Total intervention costs were C$223,691 (C$838 per physician and C$74,564 per release). Costs incurred during the development phase accounted for 74% of the total cost (C$166,117), while implementation costs for three report releases were responsible for 26% of the total costs (C$57,575). The ROI for every C$1 spent on the 'MyPractice' intervention was 1.02 (95% CI 0.51, 1.93) for three report releases. CONCLUSION: 'MyPractice' report offers a good return on investment and the value for money could improve with greater number of report releases.

Return on Investment Analysis for the Integrated Parkinson's Care Network: Lesson Learned from a Pilot Study.

BACKGROUND: Parkinson's disease (PD) is a complex and debilitating condition that requires care from a multispecialty team. The Integrated Parkinson Care Network (IPCN) is an innovative pragmatic care model that focuses on integrated care, self-management support and technology-enabled care. OBJECTIVE: This study aims to estimate the costs of the IPCN and assess whether benefits gained from the intervention offset its costs based on a single center experience. METHODS: We conducted a return on investment (ROI) analysis of the IPCN from a societal perspective. The ROI for the IPCN was estimated as a ratio of the net savings and the intervention cost. The intervention cost was calculated as a sum of set-up and implementation costs. Cost savings was measured as the absolute reduction in the societal costs realized by PD patients. A positive ROI indicated that savings generated from the intervention offset its cost. RESULTS: The total cost of the IPCN for 100 PD patients was C$135,669, or C$226 per patient per month. IPCN was associated with the reduction in societal cost of C$915 per patient per month (95%CI: -2,782, 951). The ROI per PD patient per month for the IPCN was 3.08 (95%CI: -0.60, 22.93), suggesting that for every C$1 invested in the IPCN, C$4.08 is gained through reduction in societal costs. The returns were greater among advanced PD patients. CONCLUSION: The IPCN has the potential to offer a good return on investment for PD patients, and its value for money is higher among advanced PD patients.

Total Shoulder Arthroplasty Is Cost-Effective Compared with Hemiarthroplasty: A Real-World Economic Evaluation.

BACKGROUND: Although outcome studies generally demonstrate the superiority of a total shoulder arthroplasty (TSA) over a hemiarthroplasty (HA), comparative cost-effectiveness has not been well studied. From a publicly funded health-care system's perspective, this study compared the costs and quality-adjusted life-years (QALYs) in patients who underwent TSA with those in patients who underwent HA. METHODS: We conducted a cost-utility analysis using a Markov model to simulate the costs and QALYs for patients undergoing either TSA or HA over a lifetime horizon to account for costs and medically important events over the patient lifetime. Subgroup analyses by age groups (≤50 or >50 years) were performed. A series of sensitivity analyses were performed to assess robustness of study findings. The results were presented in 2019 U.S. dollars. RESULTS: TSA was dominant as it was less costly ($115,785 compared with $118,501) and more effective (10.21 compared with 8.47 QALYs) than HA over a lifetime horizon. Changes to health utility values after TSA and HA had the largest impact on the cost-effectiveness findings. At a willingness-to-pay (WTP) threshold of $50,000 per QALY gained, HA was not found to be cost-effective. The probability that TSA was cost-effective was 100%. CONCLUSIONS: Based on a WTP of $50,000 per QALY gained, from the perspective of Canada's publicly funded health-care system, TSA was found to be cost-effective in all patients, including those ≤50 years of age, compared with HA. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Cost-utility analysis of apixaban compared with usual care for primary thromboprophylaxis in ambulatory patients with cancer.

BACKGROUND: Apixaban (2.5 mg) taken twice daily has been shown to substantially reduce the risk of venous thromboembolism (VTE) compared with placebo for the primary thromboprophylaxis of ambulatory patients with cancer who are starting chemotherapy and are at intermediate-to-high risk of VTE. We aimed to compare the health system costs and health benefits associated with primary thromboprophylaxis using apixaban with those associated with the current standard of care (where no primary thromboprophylaxis is given), from the perspective of Canada's publicly funded health care system in this subpopulation of patients with cancer over a lifetime horizon. METHODS: We performed a cost-utility analysis to estimate the incremental cost per quality-adjusted life-year (QALY) gained with primary thromboprophylaxis using apixaban. We obtained baseline event rates and the efficacy of apixaban from the Apixaban for the Prevention of Venous Thromboembolism in High-Risk Ambulatory Cancer Patients (AVERT) trial on apixaban prophylaxis. We estimated relative risk for bleeding, risk of complications associated with VTE treatment, mortality rates, costs and utilities from other published sources. RESULTS: Over a lifetime horizon, apixaban resulted in lower costs to the health system (Can$7902.98 v. Can$14 875.82) and an improvement in QALYs (9.089 v. 9.006). The key driver of cost-effectiveness results was the relative risk of VTE as a result of apixaban. Results from the probabilistic analysis showed that at a willingness to pay of Can$50 000 per QALY, the strategy with the highest probability of being most cost-effective was apixaban, with a probability of 99.87%. INTERPRETATION: We found that apixaban is a cost-saving option for the primary thromboprophylaxis of ambulatory patients with cancer who are starting chemotherapy and are at intermediate-to-high risk of VTE.

Economic Analysis of Exclusive Human Milk Diets for High-Risk Neonates, a Canadian Hospital Perspective.

Background: There is increasing evidence that premature newborns and infants with low birth weight can benefit substantially from an exclusive human milk-based diet (EHMD), consisting of human milk supplemented with a pasteurized donor human milk-derived fortifier. However, compared with the standard infant diet, EHMD also represents a significant added cost to the hospital and/or health system, thereby raising important questions about the economic feasibility of incorporating EHMD into newborn care. Design: We conducted a cost analysis and estimated the potential cost savings to a Canadian tertiary hospital based on the attributable complications averted from EHMD among low-weight neonates. A meta-analysis was performed to derive input parameters. A probabilistic analysis was conducted to determine the probability that EHMD is cost saving and 95% confidence interval (CI) around our estimates. Results: Our findings show that providing EHMD to preterm infants under 750 g at birth and at the highest risk of developing major complications is likely to be cost saving in the amount of $107,567 (95% CI: -145,229 to 360,362) per year. Extending EHMD to higher weight classes may be economically feasible depending on the pricing of the human milk-derived fortifier and the baseline risk of complications in the hospital setting. Conclusions: This comprehensive study provides critical insight for hospital-based decision makers to evaluate the potential gains and uncertainties associated with improved nutritional care for neonatal patients.

Cost-effectiveness of Endoscopic Polypectomy in Clinic compared to Endoscopic Sinus Surgery: A modelling study.

OBJECTIVE: To compare costs and quality-adjusted life years of patients receiving endoscopic polypectomy in the clinic those receiving endoscopic sinus surgery from the perspective of Canada's health system. METHOD: We developed a Markov model to simulate costs and quality-adjusted life years among a cohort of patients with chronic rhinosinusitis with polyps who received endoscopic polypectomy in clinic or endoscopic sinus surgery, over a patient's lifetime. Our study focused on patients with chronic rhinosinusitis with polyps who have the predominant symptom of bilateral nasal obstruction. Cost data were obtained from Canadian sources. Health utility values were derived from Sino-nasal Outcome Test (SNOT-22) scores reported in the published literature. A cycle length of six months was used. Both costs and quality-adjusted life years were discounted using an annual rate of 1.5%. We conducted one-way and probabilistic sensitivity analyses to assess the robustness of the study findings. RESULTS: Endoscopic polypectomy in clinic was a cost-saving option as it had a lower cost (C$736 vs. C$6,728) and produced more quality-adjusted life years (13.85 vs 13.06) compared to endoscopic sinus surgery. Our findings were, however, highly sensitive to health utility values. Results from probabilistic sensitivity analysis showed that endoscopic polypectomy in clinic had a lower cost and was more effective compared to endoscopic sinus surgery in 99.86% of iterations. CONCLUSION: From the perspective of the publicly funded healthcare system, endoscopic polypectomy in clinic was economically attractive compared to endoscopic sinus surgery for chronic rhinosinusitis with polyps patients who have a primary symptom of bilateral nasal obstruction. The cost-effectiveness results are, however, highly dependent on the relative impact of endoscopic polypectomy in the clinic and endoscopic sinus surgery on post-surgery health utility values.

Perception and willingness toward oral pathology and histology as a subject and profession among Indian dental undergraduates.

BACKGROUND: Oral pathology, a branch of dentistry which is often termed as a nonclinical branch deserves a better description as fundamental knowledge of oral pathology is essential to become a successful dental clinician. This study was conducted to analyze the approach toward Oral Pathology and Histology as a subject and profession among dental undergraduates. MATERIALS AND METHODS: A questionnaire-based, cross-sectional study was conducted among 200 students which included the 3rd year, 4th year and interns studying in a Dental College in Gurugram, Haryana. The questionnaire comprised 14 close-ended questions, divided under three parameters which included demographic characteristics, students' perception about the Oral Pathology and Histology as a subject, and willingness to choose it as a career option. The data recorded was subjected to statistical analysis using the Chi-square test. The level of statistical significance was set at P ≤ 0.05. RESULTS: Among all the participants, 53 (26.5%) were males and 147 (73.5%) were females. It was found that 33.5% of the total students find the subject interesting, but 24.5% students reported their main focus on just passing this subject. Although they reported liking toward the subject, majority of them (64%) did not express their interest to pursue it as their postgraduation specialty. CONCLUSION: The present scenario of Oral Pathology and Histology as a subject is alarming and in that scenario it should be our prime concern to change the attitude of students toward the subject who perceive it as a nonclinical subject having a lesser scope for practice with a need to broaden the scope of the specialty and to make it more practical.

In patients with unprovoked VTE, does the addition of FDG PET/CT to a limited occult cancer screening strategy offer good value for money? A cost-effectiveness analysis from the publicly funded health care systems.

INTRODUCTION: Unprovoked venous thromboembolism (VTE) may be the first manifestation of an undiagnosed cancer. We assessed the cost-effectiveness of 18F-Fluorodesoxyglucose Positron Emission/Computed Tomography (FDG PET/CT) plus limited screening and limited screening strategies in patients with unprovoked VTE from the perspectives of the Ontario (Canada) and French health care systems. METHODS: We conducted a cost-effectiveness analysis based on a published randomized controlled trial of 394 patients aged 18 years or older who were diagnosed with unprovoked VTE. We obtained data with respect to efficacy and health care utilization from the published trial. The primary measure of effectiveness was the number of avoided cases of delayed cancer diagnosis and the secondary measure of effectiveness was the quality adjusted life year (QALY) at the end of the study in each group. We used generalized linear models to estimate incremental cost-effectiveness ratios (ICER) while controlling for patient demographic and clinical characteristics. Results were presented as the incremental cost to avoid one case of delayed cancer diagnosis and the incremental cost per QALY gained. The 95% confidence intervals (CIs) were estimated using bootstrap re-sampling procedures with 5000 iterations. RESULTS: Compared to a limited screening strategy, the ICER of limited strategy plus FDG PET/CT scan was C$ 26,840.19 (95% CI: C$ 24,046.51; C$ 34,581.53) per one avoided case of delayed cancer diagnosis from the Ontario health system perspective and €16,370.45 (95% CI: € 9904.48; € 39,578.91) per one avoided case of delayed cancer diagnosis from the French health system perspective. The probabilities that addition of FDG PET/CT to limited screening is cost-effective rose with increasing willingness to pay values. Compared with the limited screening, the extensive screening was associated with C$ 3412.85 per QALY gained (95% CI: 1463.89; -13,935.88) from the Ontario health system perspective and €2162.83 per QALY gained (95% CI 958.78; -10,544.42) from the French health system perspective. CONCLUSION: Addition of a FDG PET/CT for occult cancer diagnosis was associated with better health outcomes (fewer cases of delayed cancer diagnosis and greater QALYs) and a higher cost from the perspective of publicly funded health care systems; the cost-effectiveness results are however highly uncertain.