title: The value of PET/CT with FES or FDG tracers in metastatic breast cancer: a computer simulation study in ER-positive patients.
abstract: BACKGROUND
  The aim of this study was to evaluate the effect on the number of performed biopsies and costs associated with implementing positron emission tomography (PET) and computed tomography (PET/CT) with 16α-[(18)F]fluoro-17β-oestradiol (FES) or 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG) as an upfront imaging test for diagnosing metastatic breast cancer (MBC) in comparison with the standard work-up in oestrogen receptor-positive women with symptoms.
  
  
  METHODS
  A published computer simulation model was adapted and validated. Three follow-up strategies were evaluated in a simulated cohort of women with primary breast cancer over a 5-year-time horizon: (1) the standard work-up, (2) upfront FES-PET/CT and (3) upfront FDG-PET/CT. The main outcome was the number of avoided biopsies to assess MBC. The costs for all three strategies were calculated based on the number of imaging tests and biopsies. The incremental cost-effectiveness ratio (ICER) to avoid a biopsy was calculated only based on the costs of initial imaging and staging tests.
  
  
  RESULTS
  The FES-PET/CT strategy decreased the number of biopsies by 39 ± 9%, while upfront FDG-PET/CT increased the number of biopsies by 38 ± 15% when compared with the standard work-up. Both PET/CT strategies reduced the number of imaging tests and false positives when compared with the standard work-up. The number of false negatives decreased only in the FES-PET/CT strategy. The ICER in the FES-PET/CT strategy per avoided biopsy was 12.1 ± 3.4 thousand Euro. In the FDG-PET/CT strategy, the costs were higher and there were no avoided biopsies as compared with the standard work-up, hence this was an inferior strategy in terms of cost effectiveness.
  
  
  CONCLUSIONS
  The number of performed biopsies was lower in the FES-PET/CT strategy at an ICER of 12.1 ± 3.4 thousand Euro per biopsy avoided, whereas the application of the FDG-PET/CT did not reduce the number of biopsies and was more expensive. Whether the FES-PET/CT strategy has additional benefits for patients in terms of therapy management has to be evaluated in clinical studies.
authors.affiliation: Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: R G
authors.initials: RG
authors.lastname: Koleva-Kolarova
authors.affiliation: Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: M J W
authors.initials: MJ
authors.lastname: Greuter
authors.affiliation: Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: van Kruchten
authors.affiliation: Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: K M
authors.initials: KM
authors.lastname: Vermeulen
authors.affiliation: 1] Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands [2] RIVM, Antonie van Leeuwenhoeklaan, 3721MA Bilthoven, The Netherlands.
authors.forename: T
authors.initials: T
authors.lastname: Feenstra
authors.affiliation: Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: E
authors.initials: E
authors.lastname: Buskens
authors.affiliation: Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: A W J M
authors.initials: AW
authors.lastname: Glaudemans
authors.affiliation: Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: E F J
authors.initials: EF
authors.lastname: de Vries
authors.affiliation: Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: E G E
authors.initials: EG
authors.lastname: de Vries
authors.affiliation: Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: G A P
authors.initials: GA
authors.lastname: Hospers
authors.affiliation: Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713GZ Groningen, The Netherlands.
authors.forename: G H
authors.initials: GH
authors.lastname: de Bock
mesh_terms: D001706:Biopsy / Q000191:economics / Q000379:methods; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000235:genetics / Q000378:metabolism / Q000473:pathology; D003198:Computer Simulation; D003952:Diagnostic Imaging / Q000379:methods; D004958:Estradiol / Q000031:analogs & derivatives*; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D009362:Neoplasm Metastasis; D009367:Neoplasm Staging / Q000379:methods; D049268:Positron-Emission Tomography / Q000379:methods; D019275:Radiopharmaceuticals; D011960:Receptors, Estrogen / Q000096:biosynthesis* / Q000235:genetics; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000379:methods
chemical_list: D019275:Radiopharmaceuticals; D011960:Receptors, Estrogen; D019788:Fluorodeoxyglucose F18; D004958:Estradiol; C043436:16-fluoroestradiol