Additional MRI for initial M-staging in pancreatic cancer: a cost-effectiveness analysis

Abstract

Objective: Pancreatic cancer is portrayed to become the second leading cause of cancer-related death within the next years. Potentially complicating surgical resection emphasizes the importance of an accurate TNM classification. In particular, the failure to detect features for non-resectability has profound consequences on patient outcomes and economic costs due to incorrect indication for resection. In the detection of liver metastases, contrast-enhanced MRI showed high sensitivity and specificity; however, the cost-effectiveness compared to the standard of care imaging remains unclear. The aim of this study was to analyze whether additional MRI of the liver is a cost-effective approach compared to routinely acquired contrast-enhanced computed tomography (CE-CT) in the initial staging of pancreatic cancer.

Methods: A decision model based on Markov simulation was developed to estimate the quality-adjusted life-years (QALYs) and lifetime costs of the diagnostic modalities. Model input parameters were assessed based on evidence from recent literature. The willingness-to-pay (WTP) was set to $100,000/QALY. To evaluate model uncertainty, deterministic and probabilistic sensitivity analyses were performed.

Results: In the base-case analysis, the model yielded a total cost of $185,597 and an effectiveness of 2.347 QALYs for CE-MR/CT and $187,601 and 2.337 QALYs for CE-CT respectively. With a net monetary benefit (NMB) of $49,133, CE-MR/CT is shown to be dominant over CE-CT with a NMB of $46,117. Deterministic and probabilistic survival analysis showed model robustness for varying input parameters.

Conclusion: Based on our results, combined CE-MR/CT can be regarded as a cost-effective imaging strategy for the staging of pancreatic cancer.

Key points: • Additional MRI of the liver for initial staging of pancreatic cancer results in lower total costs and higher effectiveness. • The economic model showed high robustness for varying input parameters.

Keywords: Cancer staging; Cost-effectiveness; Magnetic resonance imaging; Multidetector computed tomography; Pancreatic neoplasms.

Fig. 1

a Effective alternative to CE-CT schematic overview of the decision model for both diagnostic strategies (CE-CT and CE-MR/CT). Markov model analysis was conducted for each outcome. b The Markov model with the respective states and their potential transition. The initial state was determined by the outcome in the decision model. TP, true positive; TN, true negative; FP, false positive; FN, false negative, CT, computed tomography; MRI, magnetic resonance imaging

Fig. 2

Scatterplot of cost and effectiveness of CE-MR/CT and CE-CT for exemplary iterations. CT, computed tomography; MRI, magnetic resonance imaging

Fig. 3

Results of the deterministic sensitivity analysis visualized as a tornado diagram, showing the influence of input parameter variation on the incremental cost-effectiveness ratio (ICER). MRI, magnetic resonance imaging; EV, expected value at base case scenario; M1, metastasized

Fig. 4

Sensitivity analysis of the net monetary benefit (NMB) with respect to the probability of possible tumor resection. CE-MR/CT has a higher NMB up to a hypothetical resectability rate of higher than 0.98