PET-CT is Cost-Effective for N2 Disease After Chemoradiotherapy

Clinical Question: Is positron emission tomography-computerized tomography (PET-CT) scanning cost-effective for the management of the neck after chemoradiotherapy (CRT)?

Background: About 70 percent of neck dissection specimens have no pathologic disease. While PET imaging is highly expensive, it is used extensively for post-treatment surveillance, even though the utility of this usage has not been well studied. Additionally, insurance providers are reluctant to reimburse protocols that require serial PET-CT imaging in today’s current healthcare climate.

Study design: Hypothetical patient case study and literature review.

Setting: Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans; and Department of Otolaryngology and Division of General Internal Medicine, University of Pittsburgh, Penn.

Synopsis: The authors conducted a cost-effectiveness analysis comparing up-front neck dissection to serial PET-CT in a hypothetical clinical scenario involving a patient with oropharyngeal cancer with pre-treatment N2 disease and having a complete response. Additionally, a literature review was performed to obtain information on incidence, probabilities and range for various clinical events in the algorithm. The team found that the PET-CT strategy would cost an average of $14,492 per patient, while neck dissection had a 0.6% percent greater efficacy in controlling neck disease, with a $22,433 incremental cost. One limitation to the study was the narrow applicability to those patients with characteristics similar to the hypothetical clinical scenario, which includes a limited follow-up period of one year.

Bottom line: The use of PET-CT imaging is the more cost-effective strategy, compared with up-front neck dissection, for surveillance of the patient with pre-treatment N2 disease, a controlled primary tumor and a clinically negative neck after completion of definitive CRT.

Reference: Rabalais A, Walvekar RR, Johnson JT, et al. A cost-effectiveness analysis of positron emission tomography-computed tomography surveillance versus up-front neck dissection for management of the neck for N2 disease after chemoradiotherapy. Laryngoscope. 2012;122(2):311-314.