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

¹ Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac St., 10th Fl., Boston, MA 02114.
² Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Boston, MA.
³ Surgical Oncology, Massachusetts General Hospital, Boston, MA.
⁴ Gastrointestinal Unit, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA.

OBJECTIVE. 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.

MATERIALS AND METHODS. 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.

RESULTS. 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.

CONCLUSION. 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.

Keywords: breast cancer • cost-effectiveness analysis • MR lymphangiography • sentinel lymph node biopsy

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