title: Cost-effectiveness of mediastinal lymph node staging in non-small cell lung cancer.
abstract: To assess the cost-effectiveness of various modes of mediastinal staging in non-small cell lung cancer (NSCLC) in a single-payer health care system.
  
  
  
  We performed a decision analysis to compare the health outcomes and costs of 4 mediastinal staging strategies: no invasive staging, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), mediastinoscopy, and EBUS-TBNA followed by mediastinoscopy if EBUS-TBNA is negative. We determined incremental cost effectiveness ratios (ICER) for all strategies and performed comprehensive deterministic sensitivity analyses using a willingness to pay threshold of $80,000/quality adjusted life year (QALY).
  
  
  
  Under the base-case scenario, the no invasive mediastinal staging strategy was least effective (QALY, 5.80) and least expensive ($11,863), followed by mediastinoscopy, EBUS-TBNA, and EBUS-TBNA followed by mediastinoscopy with 5.86, 5.87, and 5.88 QALYs, respectively. The ICER was ∼$26,000/QALY for EBUS-TBNA staging and ∼$1,400,000/QALY for EBUS-TBNA followed by mediastinoscopy. The mediastinoscopy strategy was dominated. Once pN2 exceeds 2.5%, EBUS-TBNA staging is cost-effective (∼$80,000/QALY). Once the pN2 reaches 57%, EBUS-TBNA followed by mediastinoscopy is cost-effective (ICER ∼$79,000/QALY). Once EBUS-TBNA sensitivity exceeds 25%, EBUS-TBNA staging is cost-effective (ICER ∼$79,000/QALY). Once pN2 exceeds 25%, confirmatory mediastinoscopy should be added, in cases of EBUS-TBNA sensitivity ≤ 60%.
  
  
  
  Invasive mediastinal staging in NSCLC is unlikely to be cost-effective in clinical N0 patients if pN2 <2.5%. In patients with probability of mediastinal metastasis between 2.5% and 57% EBUS-TBNA is cost-effective as the only staging modality. Confirmatory mediastinoscopy should be considered in high-risk patients (pN2 > 57%) in case of negative EBUS-TBNA.
authors.affiliation: Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. Electronic address: kasia.czarnecka@uhn.ca.
authors.forename: Katarzyna
authors.initials: K
authors.lastname: Czarnecka-Kujawa
authors.affiliation: Institute of Public Health, Medical Decision Making, and Health Technology Assessment, Department of Public Health, Health Services Research, and Health Technology Assessment, University of Health Sciences, Medical Informatics, and Technology, Tirol, Austria.
authors.forename: Ursula
authors.initials: U
authors.lastname: Rochau
authors.affiliation: Institute of Public Health, Medical Decision Making, and Health Technology Assessment, Department of Public Health, Health Services Research, and Health Technology Assessment, University of Health Sciences, Medical Informatics, and Technology, Tirol, Austria; Center for Personalized Cancer Medicine, Innsbruck, Austria; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health and Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Center for Health Decision Science, Boston, Mass.
authors.forename: Uwe
authors.initials: U
authors.lastname: Siebert
authors.affiliation: Biostatistics Department, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada.
authors.forename: Eshetu
authors.initials: E
authors.lastname: Atenafu
authors.affiliation: Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Gail
authors.initials: G
authors.lastname: Darling
authors.affiliation: Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Thomas Kenneth
authors.initials: TK
authors.lastname: Waddell
authors.affiliation: Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Pierre
authors.affiliation: Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Marc
authors.initials: M
authors.lastname: De Perrot
authors.affiliation: Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Cypel
authors.affiliation: Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Shaf
authors.initials: S
authors.lastname: Keshavjee
authors.affiliation: Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Yasufuku
mesh_terms: D002289:Carcinoma, Non-Small-Cell Lung; D003362:Cost-Benefit Analysis; D019160:Endosonography; D006801:Humans; D008175:Lung Neoplasms; D008198:Lymph Nodes; D008482:Mediastinum; D009367:Neoplasm Staging; D012680:Sensitivity and Specificity
keywords: EBUS-TBNA; cost-effectiveness; mediastinal lymph node staging; mediastinoscopy