Optimizing Diagnostic and Staging Pathways for Suspected Lung Cancer: A Decision Analysis.
Chest
; 160(6): 2304-2323, 2021 12.
Article
in En
| MEDLINE
| ID: mdl-34256049
ABSTRACT
BACKGROUND:
The optimal diagnostic and staging strategy for patients with suspected lung cancer is not known. RESEARCH QUESTION What diagnostic and staging strategies are most cost-effective for lung cancer? STUDY DESIGN ANDMETHODS:
A decision model was developed by using a hypothetical patient with a high probability of lung cancer. Sixteen unique permutations of bronchoscopy with fluoroscopy, radial endobronchial ultrasound, electromagnetic navigation, convex endobronchial ultrasound with or without rapid-onsite evaluation (ROSE), CT-guided biopsy (CTBx), and surgery were evaluated. Outcomes included cost, complications, mortality, time to complete the evaluation, rate of undetected N2-3 disease at surgery, incremental cost-complication ratio, and willingness-to-pay thresholds. Sensitivity analyses were performed on primary outcomes.RESULTS:
For a peripheral lung lesion and radiographic N0 disease, the best bronchoscopy strategy costs $1,694 more than the best CTBx strategy but resulted in fewer complications (risk difference, 14%). The additional cost of bronchoscopy to avoid one complication from a CTBx strategy was $12,037. The cost and cumulative complications of bronchoscopy strategies increased compared with CTBx strategies for small lesions. The cost and cumulative complications of bronchoscopy strategies decreased compared with CTBx strategies when a bronchus sign was present, but bronchoscopy remained more costly overall. For a central lesion and/or radiographic N1-3 disease, convex endobronchial ultrasound with ROSE followed by lung biopsy with incremental cost-effectiveness ratio, if required, was more cost-effective than any CTBx strategy across all outcomes. Strategies with ROSE were always more cost-effective than those without, irrespective of scenario. Trade-offs also exist between different bronchoscopy strategies, and optimal choices depend on the value placed on individual outcomes and willingness-to-pay.INTERPRETATION:
The most cost-effective strategies depend on nodal stage, lesion location, type of peripheral bronchoscopic biopsy, and the use of ROSE. For most clinical scenarios, many strategies can be eliminated, and trade-offs between the remaining competitive strategies can be quantified.Key words
Full text:
1
Collection:
01-internacional
Database:
MEDLINE
Main subject:
Decision Trees
/
Lung Neoplasms
Type of study:
Diagnostic_studies
/
Health_economic_evaluation
/
Prognostic_studies
Aspects:
Patient_preference
Limits:
Aged
/
Female
/
Humans
/
Male
Language:
En
Journal:
Chest
Year:
2021
Document type:
Article
Affiliation country:
Canadá