Staging MR Lymphangiography of the Axilla for Early Breast Cancer: Cost-Effectiveness Analysis

Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac St., 10th Fl., Boston, MA 02114, USA.
American Journal of Roentgenology (Impact Factor: 2.74). 12/2008; 191(5):1308-19. DOI: 10.2214/AJR.07.3861
Source: PubMed

ABSTRACT The purpose of this study was to compare the cost-effectiveness of MR lymphangiography-based strategies with that of sentinel lymph node (SLN) biopsy alone in the axillary staging of early breast cancer.
A decision-analytic Markov Model was developed to estimate quality-adjusted life expectancy and lifetime costs among 61-year-old women with clinically node-negative early breast cancer. Three axillary staging strategies were compared: MR lymphangiography alone, combined MR lymphangiography-SLN biopsy, and SLN biopsy alone. The model incorporated treatment decisions, outcome, and costs consequent to axillary staging results. An incremental cost-effectiveness analysis was performed to compare strategies. The effect of changes in key parameters on results was addressed in sensitivity analysis.
In the base-case analysis, combined MR lymphangiography-SLN biopsy was associated with the highest quality-adjusted life expectancy (13.970 years) and cost ($63,582), followed by SLN biopsy alone (13.958 years, $62,462) and MR lymphangiography alone (13.957 years, $61,605). MR lymphangiography-SLN biopsy and SLN biopsy both were associated with higher life expectancy and cost relative to those of MR lymphangiography. MR lymphangiography-SLN biopsy, however, was associated with greater overall life expectancy and greater added life expectancy per dollar than was SLN biopsy. SLN biopsy alone therefore was not considered cost-effective, but MR lymphangiography and MR lymphangiography-SLN biopsy remained competing choices. Preference of MR lymphangiography strategies was most dependent on the sensitivity of MR lymphangiography and SLN biopsy and on the quality-of-life consequences of SLN biopsy and axillary lymph node dissection, but otherwise was stable across most parameter ranges tested.
From a cost-effectiveness perspective, MR lymphangiography strategies for axillary staging of early breast cancer are preferred over SLN biopsy alone. The sensitivity of MR lymphangiography is a critical determinant of the cost-effectiveness of MR lymphangiography strategies and merits further investigation in the care of patients with early breast cancer.

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