increase of 0.04 QALYs per patient. The estimated ICER of the PET strategy compared to the
thoractomy strategy was £7,200 per QALY gained.
In the radiotherapy model only two strategies were compared. The first was that all
patients go straight to radiotherapy and the second was that all patients have a PET scan and
then receive active supportive care (M1), thoractomy (N0/1) or radical radiotherapy (N2/3).
Compared to the radiotherapy strategy the PET strategy had less futile radiotherapies and some
patients benefiting from curative surgery. However, some patients missed radical
radiotherapies and some had unnecessary surgery. Overall, the estimated incremental cost was
£9,489 per QALY gained showing PET to be a cost effective strategy rather than sending
patients straight to radiotherapy.
Other International Studies
There are three further cost effectiveness studies that show similar results to the HTBS
and NICE studies that a mediastinoscopy after positive PET is the most cost effective strategy.
All were based on decision analyses. Dietlein found that this strategy in CT negative patients
had a cost per life years (LYs) gained of €143, and in CT positive patients a cost per LYG of
€36,667.19 Scott et al found like the HTBS report that this strategy was only cost effective in
negative patients.20 While Gambhir et al did not evaluate PET separately but found overall that
using this strategy for both positive and negative patients resulted in savings of $1,154 per
patient without a loss of life expectancy.21 The Hayashi et al cost utility study also confirmed
the mediastinoscopy after positive PET strategy more cost effective than just conventional
imaging with an ICER of $US7,555 per QALY for patients with 20% mediastinal metastasis
ranging up to $44,000 per QALY for patients with 80% mediasstinal metaststasis, they did not
differentiate between CT positive and CT negative patients.
The cost effectiveness study by Verboom22 based on Dutch randomised control trial
undertaken by Van Tinternern et al23 compared a CWU with a CWU + PET strategy. The
study showed that the additional use of PET in the staging of patients with NSCLC reduced
unnecessary thoractomies by 20% when compared to CWU and saved costs. On the other
hand, the economic evaluation conducted alongside Viney’s Australian randomised control
trial suggested that only 0.22 thoractomies were avoided between the no PET and PET arms.
However, this trial only recruited stage I and II candidates who have a low probability of
mediastinal lymph node involvement or distant metastasis reducing the likelihood of a futile
thoractomy and so in this case PET was found not to be cost effective.24
Therefore, the literature suggests that PET is a cost effective study when used in
conjunction with a mediastinoscopy after a positive result in CT negative patients compared to
19 Dietlein, M., K. Weber, et al. (2000). "Cost-effectiveness of FDG-PET for the management of potentially
operable non-small cell lung cancer: priority for a PET-based strategy after nodal-negative CT results." Eur J Nucl
Med 27(11): 1598-609
20 Scott, W. J., J. Shepherd, et al. (1998). "Cost-effectiveness of FDG-PET for staging non-small cell lung cancer:
a decision analysis." Ann Thorac Surg 66(6): 1876-83; discussion 1883-5.
21Gambhir, S. S., C. K. Hoh, et al. (1996). "Decision tree sensitivity analysis for cost-effectiveness of FDG-PET in
the staging and management of non-small-cell lung carcinoma." J Nucl Med 37(9): 1428-36
22 Verboom, P., H. van Tinteren, et al. (2003). "Cost-effectiveness of FDG-PET in staging non-small cell lung
cancer: the PLUS study." Eur J Nucl Med Mol Imaging 30(11): 1444-9.
23 van Tinteren, H., O. S. Hoekstra, et al. (2002). "Effectiveness of positron emission tomography in the
preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised
trial." Lancet 359(9315): 1388-93.
24 Viney, R. C., M. J. Boyer, et al. (2004). "Randomized controlled trial of the role of positron emission
tomography in the management of stage I and II non-small-cell lung cancer.[see comment]." Journal of Clinical
Oncology 22(12)
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