Staging MR Lymphangiography of the Axilla for Early Breast Cancer: Cost-Effectiveness Analysis
Pari V. Pandharipande1,2,
Mukesh G. Harisinghani2,
Elissa M. Ozanne1,
Michelle C. Specht3,
Chin Hur4,
Janie M. Lee1 and
G. Scott Gazelle1
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.
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Fig. 1 —Decision tree for axillary staging of early breast cancer.
Three staging strategies were considered: MR lymphangiography, sentinel lymph
node (SLN) biopsy, and combined MR lymphangiography–SLN biopsy. Strategy
called no staging was included as comparator strategy only.
Strategies are depicted to right of square branch point, termed decision node.
To right of strategies are multiple circle branch points (termed chance
nodes), which reflect probabilistic states and outcomes. For each staging
strategy, there are associated probabilities of both correct (TP =
true-positive, TN = true-negative) and incorrect (FP = false-positive, FN =
false-negative) staging. Terminal nodes (M) signify that Markov model,
informed by staging results, defines ensuing pathway.
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Fig. 2 —Markov model for simulating outcomes for 61-year-old women
with early-stage breast cancer treated with breast conservation surgery and
radiation therapy. Simulated cohort entered receiving adjuvant
therapy health state after axillary staging and treatment. After
completion of adjuvant therapy, patients transited to postadjuvant
therapy state. Each year, patients could develop metastatic disease or
die of unrelated causes. Patients in metastatic breast cancer state
could die of cancer or noncancer causes. Cohort's cumulative incurred time and
expenses in each health state were summed, enabling calculation of
strategy-specific life expectancy and lifetime costs.
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Fig. 3 —Graph shows comparison of axillary staging strategies in
cost-effectiveness space. Efficiency frontier (dashed line) within
cost-effectiveness space shows diminishing marginal returns for higher-cost
strategies and shows weakly dominated strategy (sentinel lymph node [SLN]
biopsy) falling below frontier. Triangle indicates no treatment; square, MR
lymphangiography alone; x, SLN biopsy alone; diamond, combined MR
lymphangiography and SLN biopsy.
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Fig. 4 —Chart shows strategy dominance as function of sensitivity of
MR lymphangiography and sentinel lymph node (SLN) biopsy. Across most MR
lymphangiography and SLN biopsy sensitivity ranges (upper and
lower bar, respectively) tested for axillary malignancy detection, MR
lymphangiography–based strategies dominated SLN biopsy from
cost-effectiveness standpoint. Asterisk indicates that at MR lymphangiography
sensitivity of 1.0, MR lymphangiography strongly dominates both SLN biopsy and
combined MR lymphangiography and SLN biopsy.
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Fig. 5 —Graph shows staging strategy preference as function of
long-term quality-of-life sequelae from sentinel lymph node (SLN) biopsy and
axillary lymph node dissection. Strategy preference was sensitive to utility
adjustments that accounted for potential long-term adverse effects of SLN
biopsy and axillary lymph node dissection. For most utility values considered,
MR lymphangiography alone was preferred (MR lymphangiography had greater
associated quality-adjusted life expectancy than other strategies and was not
strongly or weakly dominated). If both procedural utility values were very
high, combined MR lymphangiography and SLN biopsy was preferred. However, if
post–SLN biopsy utilities were very high and if post–axillary
lymph node dissection utilities were relatively slightly lower, SLN biopsy
alone was preferred. Because of lack of published data to inform values, no
utility adjustments were made in base-case analysis.
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Fig. 6 —Graph shows staging strategy preference as function of
sensitivity of MR lymphangiography and sentinel lymph node (SLN) biopsy. For
each possible combination of MR lymphangiography sensitivity and SLN biopsy
sensitivity, preferred strategies were considered those yielding greatest
number of quality-adjusted life years without being strongly or weakly
dominated. Combined MR lymphangiography–SLN biopsy was preferred for
most combinations of MR lymphangiography and SLN biopsy sensitivity. However,
if SLN biopsy sensitivity was very high and MR lymphangiography sensitivity
was slightly lower, SLN biopsy alone was preferred.
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Copyright © 2008 by the American Roentgen Ray Society.
