Cost-effectiveness analysis of FDG PET-CT in the management of pulmonary metastases from malignant melanoma

Figures & data

Figure 1. Health state diagram.

This model considers one cycle to be one month, accounting for each time a patient underwent surgery or chemotherapy. Note that resectable pulmonary metastatic disease, recurrence free survival after resection of the pulmonary metastastic disease and systemic treatment were subdivided in two different episodes as sometimes two subsequent metastasectomies may occur. The diamond represent the different absorbing states: death of other causes, lung metastatic disease related death and other metastases related death.

Table I. Clinical baseline model estimates.

	Mean	Sensitivity analysis ranges	St Dev	Distribution	Alpha	Beta	References
Clinical Variables
Probabilities
Candidates for surgery	0.16	0.11–0.19	0.03	Beta	21.42	114.55	[4, 5, 15, 53]
Peri-operative mortality	0.01	0.00–0.03	0.01	Beta	0.85	75.72	[5, 6, 16, 39, 54–57]
Complete resection	0.84	0.61–1.00	0.15	Beta	4.46	0.84	[4–6, 15, 16, 58, 59]
Uncomplete resection	0.16	0.00–0.39	0.15	Beta	0.84	4.46	[4–6, 15, 16, 58, 59]
Risk of recurrence after metastasectomy ^b	0.70	0.39–0.88	0.17	Beta	4.42	1.90	[15, 16, 27, 39, 59, 60]
Fraction of pulmonary recurrence	0.34	0.27–0.43	0.06	Beta	18.39	35.07	[15, 16, 27, 59, 60]
Candidates for second resection	0.36	0.17–0.58	0.17	Beta	2.50	4.50	[16, 27, 60]
Dacarbazine complete response rate^c	0.03	0.02–0.05	0.01	Beta	6.87	199.27	[2, 13, 32, 34–36]
Dacarbazine partial response rate	0.15	0.10–0.20	0.04	Beta	11.32	64.17	[32, 34–36, 61]
Transition probabilities
Risk of developing lung metastases	vary over time	+/− 20%		Uniform			[4]
Death of other causes	vary over time	+/− 20%		Uniform			[31]
Melanoma related death	vary over time	+/− 20%		Uniform			[4]
Risk of developing other metastases	vary over time	+/− 20%		Uniform			[1, 2]
Imaging characteristics
WB CT-scan sensitivity	0.78	0.68–0.88	0.053	Normal			[51, 52, 62]
WB CT-scan specificity	0.92	0.86–0.95	0.029	Normal			[51, 52, 62]
PET-CT sensitivity	0.94	0.90–0.97	0.020	Normal			[51, 52, 62]
PET-CT specificity	0.95	0.88–1.00	0.035	Normal			[51, 52, 62]

(a) Operable metastases have been defined as oligometastatic lung disease, Karnofsky Performance Status > 80 and no evidence of occult extra-thoracic disease.

(b) Median recurrence period of 9 months

(c) No benefit of any treatment on long-term survival was obvious with 13.6% 2nd year, 9.7% 3rd year and 2.3% 5th year survival.

Table II. Economical baseline model estimates.

	Mean (€)	Sensitivity analysis Ranges (€)	St Dev (€)	Distribution
Economical Variables
Cost screening (visit, blood sampling and chest-XR)	100	80–120	–	Triangular
Cost surgery & potential complications	7 615	3 510–27 574	3 788	Gamma
Total cost for chemotherapy & complications	5 599	413–17 539	4 475	Gamma
Cost palliative treatment	4 985	675–17 627	4 634	Gamma
Cost PET-CT study	1 120	896–1 344	–	Triangular
Cost WB-CT study	725	580–870	–	Triangular
Discount of the costs	3%
Discount of the effects	1.5%

Figure 2. Tornado diagram of univariate analyses. This diagram shows the degree to which uncertainty in individual variables affects ICER. Other parameters also evaluated but without influence on the ICER were Sensitivity and Specificity of the WB-CT scan, cost of the WB-CT scan and the probability to die from other metastases.

Table III. Deterministic analysis Costs, life months gained, cost-effectiveness ratio, and incremental cost-effectiveness ratio of the screening regimens over a 10 years period.

Strategy	Costs (€)	Incremental cost (€)	Effects	Incremental effect	Average C/E (€)	ICER (€)
Costs per LMG (discounted costs and effects)
PET-CT	€ 3 438		90.61 LMG		€ 379.40
WB-CT	€ 4 384	€ 946	90.42 LMG	−0.1929 LMG	€ 484.85	Dominated
Costs per LMG (discounted costs)
PET-CT	€ 3 438		97.15 LMG		€ 353.87
WB-CT	€ 4 384	€ 946	96.93 LMG	−0.2121 LMG	€ 452.26	Dominated

*Discounted at the rate of 3% for the costs and 1.5% for the effects.

C/E (Cost-Effectiveness Ratio), Incremental Cost-Effectiveness Ratio (ICER), LMG (Life-Months Gained), WB-CT (whole-body CT scan), PET-CT (Hybrid Imaging with Positron Emission Tomography and a CT scan).

Figure 3. Incremental Cost and Effectiveness (LMG) of PET-CT over Conventional Strategy. This scatter plot shows the distribution of 1 000 trials from the Monte Carlo simulation.

Figure 4. Net health benefit acceptability curves.

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