title: Cost-effectiveness of response evaluation after chemoradiation in patients with advanced oropharyngeal cancer using18F-FDG-PET-CT and/or diffusion-weighted MRI.
abstract: Considerable variation exists in diagnostic tests used for local response evaluation after chemoradiation in patients with advanced oropharyngeal cancer. The yield of invasive examination under general anesthesia (EUA) with biopsies in all patients is low and it may induce substantial morbidity. We explored four response evaluation strategies to detect local residual disease in terms of diagnostic accuracy and cost-effectiveness.
  
  
  
  We built a decision-analytic model using trial data of forty-six patients and scientific literature. We estimated for four strategies the proportion of correct diagnoses, costs concerning diagnostic instruments and the proportion of unnecessary EUA indications. Besides a reference strategy, i.e. EUA for all patients, we considered three imaging strategies consisting of18FDG-PET-CT, diffusion-weighted MRI (DW-MRI), or both18FDG-PET-CT and DW-MRI followed by EUA after a positive test. The impact of uncertainty was assessed in sensitivity analyses.
  
  
  
  The EUA strategy led to 96% correct diagnoses. Expected costs were €468 per patient whereas 89% of EUA indications were unnecessary. The DW-MRI strategy was the least costly strategy, but also led to the lowest proportion of correct diagnoses, i.e. 93%. The PET-CT strategy and combined imaging strategy were dominated by the EUA strategy due to respectively a smaller or equal proportion of correct diagnoses, at higher costs. However, the combination of PET-CT and DW-MRI had the highest sensitivity. All imaging strategies considerably reduced (unnecessary) EUA indications and its associated burden compared to the EUA strategy.
  
  
  
  Because the combined PET-CT and DW-MRI strategy costs only an additional €927 per patient, it is preferred over immediate EUA since it reaches the same diagnostic accuracy in detecting local residual disease while leading to substantially less unnecessary EUA indications. However, if healthcare resources are limited, DW-MRI is the strategy of choice because of lower costs while still providing a large reduction in unnecessary EUA indications.
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing ST, 1007, MB, Amsterdam, the Netherlands. mj.greuter@vumc.nl.
authors.forename: Marjolein Je
authors.initials: MJ
authors.lastname: Greuter
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, PO Box 7057, 1007, MB, Amsterdam, the Netherlands.|Department of Otorhinolaryngology-Head and Neck Surgery, Radboud University Medical Center Nijmegen, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
authors.forename: Charlotte S
authors.initials: CS
authors.lastname: Schouten
authors.affiliation: Department of Radiology and Nuclear medicine, VU University Medical Center, PO Box 7057, 1007, MB, Amsterdam, the Netherlands.
authors.forename: Jonas A
authors.initials: JA
authors.lastname: Castelijns
authors.affiliation: Department of Radiology and Nuclear medicine, VU University Medical Center, PO Box 7057, 1007, MB, Amsterdam, the Netherlands.
authors.forename: Pim
authors.initials: P
authors.lastname: de Graaf
authors.affiliation: Department of Radiology and Nuclear medicine, VU University Medical Center, PO Box 7057, 1007, MB, Amsterdam, the Netherlands.
authors.forename: Emile Fi
authors.initials: EF
authors.lastname: Comans
authors.affiliation: Department of Radiology and Nuclear medicine, VU University Medical Center, PO Box 7057, 1007, MB, Amsterdam, the Netherlands.
authors.forename: Otto S
authors.initials: OS
authors.lastname: Hoekstra
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, PO Box 7057, 1007, MB, Amsterdam, the Netherlands.|Department of Head and Neck Surgical Oncology, UMC Utrecht Cancer Center, University Medical Cancer Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands.
authors.forename: Remco
authors.initials: R
authors.lastname: de Bree
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing ST, 1007, MB, Amsterdam, the Netherlands.
authors.forename: Veerle Mh
authors.initials: VM
authors.lastname: Coupé
mesh_terms: D000328:Adult; D000368:Aged; D059248:Chemoradiotherapy; D003362:Cost-Benefit Analysis; D038524:Diffusion Magnetic Resonance Imaging / Q000191:economics* / Q000379:methods; D005260:Female; D019788:Fluorodeoxyglucose F18 / Q000378:metabolism; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D064847:Multimodal Imaging / Q000191:economics* / Q000379:methods; D009367:Neoplasm Staging; D009959:Oropharyngeal Neoplasms / Q000000981:diagnostic imaging / Q000191:economics* / Q000473:pathology / Q000628:therapy; D000072078:Positron Emission Tomography Computed Tomography / Q000191:economics* / Q000379:methods; D011379:Prognosis; D019275:Radiopharmaceuticals / Q000378:metabolism
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18
keywords: 18F-FDG-PET-CT; Cost-effectiveness; Diffusion-weighted MRI; Oropharyngeal cancer; Response evaluation