Economic analysis of combined endoscopic and endobronchial ultrasound in the evaluation of patients with suspected non-small cell lung cancer
Introduction
Lung cancer remains the most common cause of cancer death in the United States. The optimal treatment for patients with non-small cell lung cancer (NSCLC) is surgical resection. Unfortunately, metastatic involvement of mediastinal lymph nodes (stage III disease) precludes surgery in most cases; N2 disease is defined as involvement of the ipsilateral mediastinal lymph nodes, while N3 disease involves contralateral nodes. The 5-year survival rate for patients with N2 disease detectable on preoperative computed tomography (CT) is universally poor after surgical resection, ranging from 3% to 8% [1], [2], [3], [4], [5], [6], [7]. Consequently, it is crucially important to detect stage III disease, so that these patients may avoid unnecessary surgery.
Although thoracic CT is the most commonly used non-invasive staging modality of the mediastinum, it cannot always reliably differentiate between benign and malignant mediastinal nodes, as enlarged nodes may also be inflammatory, whereas normal-sized lymph nodes may contain malignancy [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]. Procedures that facilitate sampling of mediastinal nodes, such as endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA), endobronchial ultrasound (EBUS) FNA, mediastinoscopy and transbronchial needle aspiration (TBNA), have become established means for tissue confirmation. EUS FNA of posterior mediastinal lymph nodes is a highly accurate modality for cytodiagnosis [11], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36]. Mediastinoscopy, on the other hand, offers visualization as well as tissue diagnosis of accessible lymph node stations, but is an invasive procedure, carries a substantial cost, and has a small but definite morbidity [12], [14], [19], [35], [37], [38], [39], [40], [41], [42], [43]. TBNA has been used to evaluate suspicious subcarinal, paratracheal and hilar lymph nodes [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], but its blind approach is a limitation. More recently, EBUS FNA has emerged as an approach to overcome this limitation [54], [55], [56].
This study aimed to compare the costs of alternative diagnostic approaches in modeled patients with non-small cell lung cancer (NSCLC), using a cost-minimization approach.
Section snippets
Methods
We used standard decision analysis software (DATA 3.5, TreeAge Software Inc., Williamstown, MA) to construct our decision model (Fig. 1). Decision analysis uses data available in the medical literature to produce a model of possible outcomes associated with a particular disease, in order to facilitate the determination of the most economical health care strategy, among different alternatives. The model attaches costs and health outcomes to each health state, and estimates the total costs and
Base-case analysis
For the base-case, initial EUS FNA biopsy was the most economical strategy ($18,603) compared with the other options: EBUS FNA ($19,828), TBNA ($21,136), mediastinoscopy ($20,157), combined EUS FNA/EBUS FNA ($18,753), combined EUS FNA/TBNA ($18,838) and combined EBUS FNA/TBNA ($20,260).
Sensitivity analysis
One-way sensitivity analyses showed initial EUS FNA remained the least costly option provided the probability of lymph node metastases was <32.9%, cost $18,170 (Fig. 2); above this probability combined EUS
Discussion
This economic analysis simulates the clinical scenario of a patient with known or suspected NSCLC. The validity of any model and its conclusions can only be verified by prospective trials. For this reason, we relied on the majority of our parameter values from the only prospective trial to date comparing the performance of EUS FNA, EBUS FNA, TBNA and combinations of these tests [57]. The findings illustrate that the least costly approach of investigating these patients is predicated on the
Conflict of interest statement
None.
Acknowledgment
We would like to thank Diane Morell for editorial review of this manuscript.
Role of the funding source: None.
References (64)
- et al.
Results of surgical treatment of non-small cell lung cancer: validation of the new postoperative pathologic TNM classification
J Thorac Cardiovasc Surg
(2000) - et al.
How should interlobar pleural invasion be classified? Prognosis of resected T3 non-small cell lung cancer
Ann Thorac Surg
(1999) - et al.
Prognosis of completely resected pN2 non-small cell lung carcinomas: what is the significant node that affects survival?
J Thorac Cardiovasc Surg
(1999) - et al.
The prognosis of surgically resected N2 non-small cell lung cancer: the importance of clinical N status
J Thorac Cardiovasc Surg
(1999) - et al.
Survival and prognostic factors in resected N2 non-small cell lung cancer: a study of 140 cases. Leuven Lung Cancer Group
Ann Thorac Surg
(1997) Chest CT for known or suspected lung cancer
Chest
(1994)- et al.
Roentgenographic evaluation of mediastinal nodes for preoperative assessment in lung cancer
Chest
(1985) CT of mediastinal lymph nodes in patients with non-small cell lung carcinoma
Radiol Clin North Am
(1990)- et al.
Endoscopic ultrasound examination for mediastinal lymph node metastases of lung cancer
Chest
(1990) - et al.
Endoscopic ultrasonography and real-time guided fine-needle aspiration biopsy of solid lesions of the mediastinum suspected of malignancy
Chest
(1996)
Endoscopic ultrasonography-guided fine-needle aspiration biopsy of lymph nodes
Gastrointest Endosc
Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment
Gastroenterology
Mediastinal lymph node detection with endosonography
Gastrointest Endosc
Fine-needle aspiration of posterior mediastinal lesions guided by radial scanning endosonography
Gastrointest Endosc
Endoscopic ultrasonography as an adjunct to fine needle aspiration cytology of the upper and lower gastrointestinal tract
Gastrointest Endosc
Endoscopic transesophageal fine needle aspiration of mediastinal masses
Gastrointest Endosc
Real-time endoscopic ultrasound-guided fine-needle aspiration of a mediastinal lymph node
Gastrointest Endosc
Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNA-based differential cytodiagnosis in 153 patients
Am J Gastroenterol
Evaluation of the mediastinum by invasive techniques
Surg Clin North Am
Role of mediastinoscopy in pretreatment staging of patients with primary lung cancer
Ann Thorac Surg
Diagnostic anterior mediastinotomy
Ann Thorac Surg
Mediastinoscopy vs thoracoscopy for mediastinal biopsy. Results of a prospective nonrandomized study
Chest
Transcarinal mediastinal needle biopsy compared with mediastinoscopy
J Thorac Cardiovasc Surg
Transbronchial needle aspiration in clinical practice. A five-year experience
Chest
Bronchoscopic and roentgenographic correlates of a positive transbronchial needle aspiration in the staging of lung cancer
Chest
The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma
Chest
Transbronchial aspiration of subcarinal lymph nodes
Br J Dis Chest
Transbronchial needle aspiration in the diagnosis of bronchogenic carcinoma
Chest
Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung
Ann Thorac Surg
Endoscopic ultrasound in lung cancer patients with a normal mediastinum on computed tomography
Ann Thorac Surg
Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)
Chest
Endoscopic ultrasound-guided fine-needle aspiration for non-small cell lung cancer staging: a systematic review and metaanalysis
Chest
Cited by (60)
Endobronchial Ultrasound for Mediastinal Staging in Lung Cancer
2021, Encyclopedia of Respiratory Medicine, Second EditionEndobronchial ultrasound-guided transbronchial needle aspiration combined with either endoscopic ultrasound-guided fine-needle aspiration or endoscopic ultrasound using the EBUS scope-guided fine-needle aspiration for diagnosing and staging mediastinal diseases: a systematic review and meta-analysis
2020, ClinicsCitation Excerpt :Since the first report (17) of the combination of EBUS-TBNA and EUS-FNA for mediastinal staging, several studies (18–26) have found that it can provide high sensitivity and specificity, which we confirm in this pooled analysis. As another advantage, this modality combination is more cost-effective than either EBUS-TBNA or EUS-FNA alone (27). On the other hand, this modality combination requires using both a bronchoscope for EBUS and an endoscope for EUS.
Endobronchial and Endoscopic Ultrasound-Guided Transvascular Biopsy of Mediastinal, Hilar, and Lung Lesions
2017, Annals of Thoracic SurgeryTen Years of Linear Endobronchial Ultrasound: Evidence of Efficacy, Safety and Cost-effectiveness
2016, Archivos de BronconeumologiaEndoscopic Mediastinal Staging in Lung Cancer Is Superior to “Gold Standard” Surgical Staging
2016, Annals of Thoracic SurgeryNodal staging in lung cancer: A risk stratification model for lymph nodes classified as negative by EBUS-TBNA
2015, Journal of Thoracic Oncology