Cost-effectiveness of Head CT in Patients With Lung Cancer Without Clinical Evidence of Metastases

doi:10.1378/chest.108.5.1264

Chest

Volume 108, Issue 5, November 1995, Pages 1264-1271

https://doi.org/10.1378/chest.108.5.1264 Get rights and content

Objective

To estimate the cost-effectiveness of CT for detecting brain lesions in patients with lung cancer without clinical evidence of metastases.

Design

Decision analysis model comparing two different strategies for detecting brain metastases: brain CT routinely (CT-first) or brain CT only when patients develop neurologic signs and/or symptoms (CT-deferred).

Patients

Hypothetical cohort of patients with lung cancer with an unremarkable screening clinical evaluation for metastases.

Measurements

Net costs are calculated as the difference in costs between the two limbs of the decision tree. Net benefits are expressed as the difference in calculated years of life expectancy between the two strategies. Net costs are divided by net benefits, yielding the marginal cost per quality adjusted year of added life expectancy (C/QALY) for the CT-first strategy.

Results

In the baseline analysis, the C/QALY for the CT-first strategy is about $70,000. Improving the clinical evaluation as a screen for detecting brain metastases markedly increases the C/QALY. Increasing the cost of brain CT magnifies this effect. More effective treatment for asymptomatic brain metastases and better accuracy of CT for identifying resectable and unresectable brain metastases lower C/QALY.

Conclusions

Although a threshold cost-effectiveness has not been defined for identifying “cost-effective” diagnostic procedures, the marginal C/QALY of the CT-first strategy is substantially higher than many accepted medical interventions. At current costs, the routine use of brain CT is not warranted in patients with lung cancer who have normal findings on a standardized clinical evaluation for metastases.

Section snippets

Calculation of Cost-effectiveness

The cost-effectiveness of a medical intervention is defined as the ratio of its costs to its expected health benefits. Health benefits may be quantified as the additional years of life expectancy achieved through use of the medical intervention. Expressing the costs of the medical intervention per years of life expectancy gained results in a common measure of cost-effectiveness that allows dissimilar medical interventions to be compared directly. In this study, we used a decision analysis model

Results

In the baseline analysis, the cost of the CT-first strategy is $11,108 and the cost for the CT-deferred strategy is $10,915. The life expectancy benefit for the CT-first strategy is about 1.1 days. The C/QALY for the CT-first strategy is calculated to be $69,815. The C/QALY for the CT-first strategy is highly sensitive to variations in the NPVhp and the cost of CT (Fig 2). As the NPVhp improves, the C/QALY of the CT-first strategy markedly increases. A higher NPVhp indicates that the screening

Discussion

As the total sum of expenditures on health care consumes an increasingly larger proportion of our nation's gross national product, physicians must more carefully analyze the economic impact of their approach to common medical problems. More specifically, they must ask what overall benefits will accrue from and what resources will be consumed by various medical interventions. With this type of analysis, some interventions will seem more appropriate than others in terms of costs vs benefits.

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Citation Excerpt :
Due to poor prognosis and limited treatment options, the finding of intracranial metastasis in NSCLC may preclude treatment with potential curative intent in favour of palliative interventions, especially if extracranial metastases are also present [23]. Hence, the potential value of brain imaging could be considered in terms of upstaging the disease, potentially avoiding unnecessary invasive and costly investigations, and preventing futile thoracotomies [3,15]. This remains the recommended approach in the UK [10] and was our rationale to introduce routine screening in our institution [12].
Although detection of brain metastasis can change treatment intent in non-small cell lung carcinoma (NSCLC), head imaging is not routinely performed during initial staging. In our previous study, 4.8% of patients considered for surgical treatment had asymptomatic synchronous brain metastases, encouraging us to include contrast-enhanced head CT (CE-CT) in our routine staging protocol. We present results from a large cohort of potentially resectable NSCLC patients imaged irrespective of the presence of neurological symptoms.
Patients with newly diagnosed NSCLC were identified from Royal Papworth Hospital registries. Data regarding the clinical stage (7th edition TNM), neurological symptoms and imaging findings were retrieved from clinical records.
1074 NSCLC patients considered potentially resectable based on the initial staging CT of the chest and abdomen (stage IA-IIIB) were included. Synchronous brain metastases were detected by CE-CT in 23 patients (2.1%); the rate of positive findings increased with stage, ranging from 0.7% (IA) to 2.6% (IIIA) (p = 0.023). The majority of metastases were asymptomatic (19 of 23, 82.6%). Asymptomatic brain lesions were smaller than symptomatic (13.3 ± 4.8 vs 24.8 ± 8.2 mm; p < 0.01); in both groups, the most frequent location was frontal lobe.
Routine CE-CT detected synchronous brain metastases in approximately 2% of NSCLC patients eligible for radical surgical treatment. The majority of the metastatic lesions were asymptomatic. With the exception of stage IA in which the detection rate is very low, CE-CT could therefore be useful in routine NSCLC staging.
Clinical Aspects of Lung Cancer
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Clinical and organizational factors in the initial evaluation of patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines
2013, Chest
This guideline is intended to provide an evidence-based approach to the initial evaluation of patients with known or suspected lung cancer. It also includes an assessment of the impact of timeliness of care and multidisciplinary teams on outcome.
The applicable current medical literature was identified by a computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. Data sources included MEDLINE and the Cochrane Database of Systematic Reviews.
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Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines
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Citation Excerpt :
Pooled sensitivity and specificity were 73% (95% CI, 60%–83%) and 85% (95% CI, 72%–92%), respectively. An association among brain metastases, N2 disease in the chest, and adenocarcinoma histology has been described.104,106,108 The FN rate of CT scanning (ie, where patients return with brain metastases within 12 months of the original scan) is reported to be 3%.106
Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making.
Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.
The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections.
Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.
A diagnostic model to detect silent brain metastases in patients with non-small cell lung cancer
2008, European Journal of Cancer
Citation Excerpt :
Therefore, computed tomography (CT) scans or magnetic resonance imaging (MRI) is recommended for cranial staging.9 However, fewer than 10% brain metastases have been detected in patients with negative neurological signs and symptoms,10 and the cost-effectiveness of routine screening for brain metastases is not clear.11 Routine screening for brain metastases in asymptomatic patients has not yet reached a consensus in practice guidelines.
We aimed to discriminate subgroups according to the risk of brain metastases in patients with non-small cell lung cancer (NSCLC) lacking neurological symptoms. We performed a retrospective review of 433 patients with NSCLC who underwent chest computed tomography (CT), brain magnetic resonance imaging (MRI) and bone scans at an initial staging work-up between April 2003 and April 2007. Brain metastases were determined by MRI. Patients were stratified into groups according to the number of risk factors (0–3) identified by multivariate analysis. In multivariate analysis, histopathology with non-squamous cell carcinoma, nodal stage ⩾2 on CT and presence of bone metastases were three risk factors for brain metastases. Patients were divided into four groups according to the number (0–3) of these predictive factors. The proportions of patients with brain metastases in the four groups were 2%, 3%, 17% and 35%, respectively, and these differences were significant (P < 0.001). When analysis was performed in patients with localised disease, the number of risk factors was correlated with the prevalence of brain metastases (P = 0.013) but stage was not (P = 0.153). Although this diagnostic model should be validated through further studies, our data suggest that the number of risk factors might be a useful tool to identify silent brain metastases in patients with NSCLC.
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Lung cancer is a common malignancy and remains the leading cause of cancer-related deaths in both men and women in the United States. Imaging plays an important role in the detection, diagnosis, and staging of the disease as well as in assessing response to therapy and monitoring for tumor recurrence after treatment. This article reviews the staging of the two major histologic categories of lung cancer—non–small-cell lung carcinoma (NSCLC) and small-cell lung carcinoma—and emphasizes the appropriate use of CT, MRI, and positron emission tomography imaging in patient management. Also discussed are proposed revisions of the International Association for the Study of Lung Cancer's terms used to describe the extent of NSCLC in terms of the primary tumor, lymph nodes, and metastases descriptors.

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: Supported by the Radiological Society of North America Research and Education Fund (Dr. Black).

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Chest

Clinical Investigations: Lung CancerCost-effectiveness of Head CT in Patients With Lung Cancer Without Clinical Evidence of Metastases

Objective

Design

Patients

Measurements

Results

Conclusions

Section snippets

Calculation of Cost-effectiveness

Results

Discussion

Chest

Chest

Chest

Chest

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Int J Radiat Oncol Biol Phys

Frequency, diagnosis, and treatment of brain metastases in 247 consecutive patients with bronchogenic carcinoma

Cancer

Silent brain metastasis from lung carcinoma determined by computerized tomography

Arch Neurol

A comparison of computed tomography and radionuclide scanning for detection of brain metastases in small cell lung cancer

J Clin Oncol

The value of routine cranial computed tomography in neurologically intact patients with primary carcinoma of the lung

Radiology

Role of computerized cranial tomography in the staging of small cell carcinoma of the lung

Cancer Treat Rep

Computed tomography of the brain, chest and abdomen in the preoperative assessment of non-small cell lung cancer

Thorax

The clinical evaluation for detecting metastatic lung cancer: a meta-analysis

Am J Respir Crit Care Med

Asymptomatic patients with primary carcinoma

NY State J Med

Clinical Investigations: Lung Cancer
Cost-effectiveness of Head CT in Patients With Lung Cancer Without Clinical Evidence of Metastases