Cost Effectiveness of Chest Computed Tomography After Lung Cancer Resection: A Decision Analysis Model

doi:10.1016/j.athoracsur.2005.04.006

The Annals of Thoracic Surgery

Volume 80, Issue 4, October 2005, Pages 1215-1223

Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.

https://doi.org/10.1016/j.athoracsur.2005.04.006 Get rights and content

Background

Postoperative surveillance with chest computed tomography (CT) is often performed in patients who have undergone resection of non-small cell lung cancer (NSCLC), despite lack of supporting data. This study involves the creation of a decision analysis model to predict the cost effectiveness of postoperative surveillance CT.

Methods

A decision analysis model was created in which a hypothetical cohort of patients underwent annual chest CT after resection of a stage IA NSCLC. The incidence of second primary lung cancer (SPLC), sensitivity and specificity of CT, as well as survival after resection of initial primary and SPLC were derived from published literature. The cost of CT and other procedures prompted by a positive finding on CT was calculated from Medicare reimbursement schedules. Cost effectiveness was defined as a cost of less than $60,000 per quality-adjusted life-year gained in the cohort under surveillance compared with controls under no surveillance.

Results

In the initial (base case) analysis, the cost of surveillance CT was $47,676 per quality-adjusted life-year gained, implying cost effectiveness. However, factors that rendered surveillance CT cost ineffective were (1) age at entry into the surveillance program greater than 65 years, (2) cost of CT greater than $700, (3) incidence of SPLC of less than 1.6% per patient per year of follow-up, and (4) a false positive rate of surveillance CT greater than 14%.

Conclusions

Surveillance with postoperative CT may be a cost-effective intervention to detect SPLC in selected patients with previously resected stage IA NSCLC.

Section snippets

Overview of the Decision Analysis Model

We evaluated the cost effectiveness of a surveillance program in which a hypothetical cohort of patients who had undergone resection of a stage IA NSCLC underwent annual CT of the chest. The survival of this cohort of patients was compared with a similar group of patients who did not undergo annual surveillance with CT (control group). The decision tree was based on a Markov model [12], in which patients transition from one health state to another on an annual basis. The probability of

Results

The 5-year survival among the surveillance patients in whom an SPLC developed was calculated by the model to be 29%, compared with 19% in the control cohort. In the base case analysis, surveillance increased overall survival by 0.16 QALY at an incremental cost of $7,716. Thus, annual CT scans were determined to be a cost-effective intervention at an overall cost of $47,676 per QALY gained.

Comment

In the United States, it has been estimated that approximately 35,000 patients undergo surgery for lung cancer each year [32]. Debate regarding the benefit of surveillance of these patients with CT scans stems from the lack of prospective data, the potential harm associated with false positive scans, and pessimism regarding the overall prognosis of patients with metachronous lung cancer.

From a strictly clinical standpoint, the rationale for offering patients surveillance CT is twofold. First,

References (49)

D. Rice et al.
The risk of second primary tumors after resection of stage I nonsmall cell lung cancer
Ann Thorac Surg
(2003)
C.H. Chiu et al.
Usefulness of low-dose spiral CT scan of the chest in regular follow-up of post-operative non-small cell lung cancer patientspreliminary report
J Thorac Cardiovasc Surg
(2003)
R.N. Younes et al.
Follow-up in lung cancerhow often and for what purpose?
Chest
(1999)
G.L. Colice et al.
Follow-up and surveillance of the lung cancer patient following curative-intent therapy
Chest
(2003)
J. Gohagan et al.
Baseline findings of a randomized feasibility trial of lung cancer screening with spiral CT scan versus chest radiographthe lung screening study of the National Cancer Institute
Chest
(2004)
S.T. Patel et al.
The cost-effectiveness of repairing ruptured abdominal aortic aneurysms
J Vasc Surg
(2000)
J.D. Birkmeyer et al.
Decision analysis modelsopening the black box
Surgery
(2003)
S. Patel et al.
Is carotid endarterectomy cost-effective in symptomatic patients with moderate (50% to 69%) stenosis?
J Vasc Surg
(1999)
S. Kilaru et al.
Is carotid angioplasty and stenting more cost effective than carotid endarterectomy?
J Vasc Surg
(2003)
T.Y. Lee et al.
The cost-effectiveness of a “quick-screen” program for abdominal aortic aneurysms
Surgery
(2002)

C.F. Mountain

Revisions in the International System for Staging Lung Cancer

Chest

(1997)

M.T. van Rens et al.

Survival after resection of metachronous non-small cell lung cancer in 127 patients

Ann Thorac Surg

(2001)

P.C. Cheung et al.

Involved-field radiotherapy alone for early-stage non-small-cell lung cancer

Int J Radiat Oncol Biol Phys

(2000)

C.I. Henschke et al.

Early lung cancer action projectoverall design and findings from baseline surveillance

Lancet

(1999)

R.J. Korst et al.

Surveillance computed tomography following complete resection for non-small cell lung cancerresults and costs

J Thorac Cardiovasc Surg

(2005)

K.S. Virgo et al.

Followup of patients with thoracic malignancies

Surg Oncol Clin North Am

(1999)

G.L. Walsh et al.

Is follow-up of lung cancer patients following resection medically indicated and effective?

Ann Thorac Surg

(1995)

K.S. Virgo et al.

Lung cancer patient follow-upmotivation of thoracic surgeons

Chest

(1998)

V. Westeel et al.

Relevance of an intensive postoperative follow-up after surgery for non-small cell lung cancer

Ann Thorac Surg

(2000)

H.-G. Eichler et al.

Use of cost-effectiveness analysis in health-care resource allocation decision-makinghow are cost-effectiveness thresholds expected to emerge?

Value Health

(2004)

Y. Saito et al.

Multicentricity in resected occult bronchogenic squamous cell carcinoma

Ann Thorac Surg

(1994)

C. Deschamps et al.

Multiple primary lung cancers. Results of surgical treatment

J Thorac Cardiovasc Surg

(1990)

T.K. Rosengart et al.

Multiple primary lung carcinomasprognosis and treatment

Ann Thorac Surg

(1991)

M.A. Razzuk et al.

Dual primary bronchogenic carcinoma

Ann Thorac Surg

(1974)

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Original articleGeneral thoracicCost Effectiveness of Chest Computed Tomography After Lung Cancer Resection: A Decision Analysis Model

Background

Methods

Results

Conclusions

Section snippets

Overview of the Decision Analysis Model

Results

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

Chest

Chest

Chest

J Vasc Surg

Surgery

J Vasc Surg

J Vasc Surg

Surgery

Chest

Ann Thorac Surg

Int J Radiat Oncol Biol Phys

Lancet

J Thorac Cardiovasc Surg

Surg Oncol Clin North Am

Ann Thorac Surg

Chest

Ann Thorac Surg

Value Health

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Original article
General thoracic
Cost Effectiveness of Chest Computed Tomography After Lung Cancer Resection: A Decision Analysis Model