Cost effectiveness of diagnostic and staging strategies for suspected lung cancer?

Abstract

A study published in Chest has found that the cost effectiveness of diagnostic and staging strategies for suspected lung cancer depend on the nodal stage, lesion location, type of peripheral bronchoscopic biopsy, and the use of rapidonsite evaluation (ROSE). The researchers developed a decision model for a hypothetical 65-year-old male outpatient smoker, with a 30mm upper lobe with a high probability of lung cancer. They evaluated 16 various combinations of bronchoscopy with fluoroscopy, radial endobronchial ultrasound (rEBUS), electromagnetic navigation, convex EBUS (cEBUS) with or without ROSE, computed tomography-guided biopsy (CTBx) and surgery. Outcomes were cost, complications, mortality, time to complete the evaluation, rate of undetected N2-3 disease at surgery, incremental cost-complication ratio, and willingness-to-pay (WTP) thresholds. For a peripheral lung lesion and radiographic N0 disease, the best bronchoscopy strategy was $US1694 more costly than the best CTBx strategy, but resulted in fewer complications. The additional cost of bronchoscopy to avoid one complication from CTBx was $12 037. The cost and cumulative complications of bronchoscopy strategies increased for small lesions, compared with CTBx strategies; in contrast, the cost and cumulative complications of bronchoscopy strategies decreased when a bronchus sign was present, but bronchoscopy was more costly overall. Of all the strategies, cEBUS with ROSE followed by lung biopsy with rEBUS, if necessary, was more cost effective than any CTBx strategy for central lesions and/or radiographic N1-3 disease. Strategies with ROSE were always more cost-effective than those without, regardless of disease scenario. The authors point out that trade-offs also exist between different bronchoscopy strategies and optimal choices depend on the value placed on individual outcomes and WTP.