ORIGINAL ARTICLE

Practice, efficacy and cost of staging suspected non-small cell lung cancer: a retrospective study in two Dutch hospitals

G J M Herder^1,5, P Verboom², E F Smit¹, P C M van Velthoven³, J H A M van den Bergh⁴, C D Colder¹, I van Mansom⁵, J C van Mourik⁶, P E Postmus¹, G J J Teule⁷, O S Hoekstra⁸

¹ Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands
² Institute of Medical Technology Assessment, Erasmus University, Rotterdam, the Netherlands
³ Department of Surgery, Medical Centre Alkmaar, Alkmaar, the Netherlands
⁴ Department of Pulmonary Medicine, Medical Centre Alkmaar
⁵ Department of Nuclear Medicine, VU University Medical Center
⁶ Department of Surgery, VU University Medical Center
⁷ Department of Nuclear Medicine and Clinical PET Centre, VU University Medical Center
⁸ Department of Nuclear Medicine and Clinical Epidemiology & Biostatistics, VU University Medical Center

Correspondence to:
Correspondence to:
Dr E F Smit, Department of Pulmonology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands;
ef.smit{at}vumc.nl

Background: A study was undertaken to investigate the clinical practice, yield, and costs of preoperative staging in patients with suspected NSCLC and to obtain baseline data for prospective studies on the cost effectiveness of ¹⁸F-fluorodeoxyglucose positron emission tomography in the management of these patients.

Methods: A retrospective study of the medical records of all patients with suspected NSCLC was performed during a 2 year interval (1993–4) in an academic and a large community hospital.

Results: Three hundred and ninety five patients with suspected NSCLC were identified; 58 were deemed to be medically inoperable and 337 patients proceeded to the staging process. Staging required a mean (SD) of 5.1 (1.5) diagnostic tests per patient (excluding thoracotomy) carried out over a median period of 20 days (IQR 10–31). Many of the tests (including both invasive and non-invasive) were done because previous imaging tests had suggested metastases, and in most cases the results of initial tests proved to be false positives. After clinical staging, 168 patients were considered to be resectable (stage I/II) and 144 patients underwent surgery with curative intent. At surgery 33 patients (23% of those who underwent surgery) were found to have irresectable lesions and 19 (13%) had a benign lesion. Surgery was also considered to be futile in 22 patients (15%) who developed metastases or local recurrence within 12 months following radical surgery. Hospital admission was responsible for most of the costs.

Conclusion: In many patients staging involved considerable effort in terms of the number of diagnostic tests, the duration of the staging period and the cost, with limited success in preventing futile surgery. Failures relate to the quality of diagnostic preparation at every level of the TNM staging system.

Keywords: non-small cell lung cancer (NSCLC); cost effectiveness; staging

Abbreviations: CT, computed tomography; NSCLC, non-small cell lung carcinoma; PET, positron emission tomography; IQR, interquartile range; FDG, ¹⁸F-fluorodeoxyglucose

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