Elsevier

Lung Cancer

Volume 67, Issue 3, March 2010, Pages 366-371
Lung Cancer

Economic analysis of combined endoscopic and endobronchial ultrasound in the evaluation of patients with suspected non-small cell lung cancer

https://doi.org/10.1016/j.lungcan.2009.04.019Get rights and content

Abstract

Lung cancer remains the most common cause of cancer-related death in the United States. This study evaluated the costs of alternative diagnostic evaluations for patients with suspected non-small cell lung cancer (NSCLC). Researchers used a cost-minimization model to compare various diagnostic approaches in the evaluation of patients with NSCLC. It was less expensive to use an initial endoscopic ultrasound (EUS) with fine needle aspiration (FNA) to detect a mediastinal lymph node metastasis ($18,603 per patient), compared with combined EUS FNA and endobronchial ultrasound (EBUS) with FNA ($18,753). The results were sensitive to the prevalence of malignant mediastinal lymph nodes; EUS FNA remained least costly, if the probability of nodal metastases was <32.9%, as would occur in a patient without abnormal lymph nodes on computed tomography (CT). While EUS FNA combined with EBUS FNA was the most economical approach, if the rate of nodal metastases was higher, as would be the case in patients with abnormal lymph nodes on CT. Both of these strategies were less costly than bronchoscopy or mediastinoscopy. The pre-test probability of nodal metastases can determine the most cost-effective testing strategy for evaluation of a patient with NSCLC. Pre-procedure CT may be helpful in assessing probability of mediastinal nodal metastases.

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.

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