Optimisation médico-économique des stratégies d'utilisation des examens TEP/TDM en imagerie oncologique

Positron emission tomography coupled with computed tomography (PET/CT) devices are essential pathways in oncology. Many studies have reported the performances of the various radiopharmaceutical drugs (RPD) used for PET/CT imaging in many cancers. The rise of PET/CT remains slowed down in France for economic reasons. However, the difference between the cost of a PET/CT examination, compared to that of another modern imaging routinely used in the same indication, is not so obvious once considered the impact on decision making and the costs avoided by the revision of erroneous or incomplete diagnoses. Nonetheless, if all PET/CT examinations are currently reimbursed in the same way regardless of the RPD used, thus making their cost identical from the health insurance perspective, their production costs for the hospital vary and should be considered according to the frequency of the indication of the examination.We compared several imaging strategies for prostate cancer imaging by analyzing the data acquired during the French prospective multicenter FLUPROSTIC study, which included two RPD for PET imaging: 18F-flurocholine (FCH) and 18F-sodium fluoride (NaF), FCH being twice more costly for the hospital than NaF.The analysis of the impact of each imaging strategy on decision making, based on dedicated questionnaires completed by the referring clinicians, demonstrated that FCH PET/CT was the imaging modality that had the highest impact, especially for patients presenting with first biochemical recurrence.The cost-utility analysis, carried out from the health insurance perspective for patients with first biochemical recurrence of prostate cancer over a "lifetime" time horizon, was based on a model5combining a decision tree integrating the diagnostic performances of imaging and a Markov model simulating the natural history of prostate cancer. This analysis demonstrated that FCH PET/CT, the most accurate imaging modality from a diagnostic point of view, had a 100% probability of being the most cost-effective strategy for willingness to pay thresholds of 3,000€ or 9,000€ per quality-adjusted life year gained if the imaging reading was made by local specialists or experts respectively. From the hospital perspective, the 20% drop in the cost of FCH between 2018 and 2019 had made profitable the production of FCH PET/CT examinations for prostate cancer imaging.PET/CT increases diagnostic accuracy and has an impact on decision making in many cancers. It helps to reduce unnecessary treatments and their potential side effects, to improve the quality of life of patients and to reduce the treatment costs for the health care system. The medico-economic evaluation of RPDs used for PET/CT imaging in oncology, in addition to that of their diagnostic performances, seems essential in order to optimize their use. In France, this evaluation should be made from both perspectives of the health insurance and the hospital. Indeed, the PET/CT production costs can largely vary for the hospital according to the RPD costs and constitute a barrier to its use, even in a frequent indication for which diagnostic performances and impact on decision making are high.Les machines de tomographie par émission de positons couplées à la tomodensitométrie (TEP/TDM) sont devenues incontournables en oncologie. De nombreuses études ont rapporté les performances des différents médicaments radiopharmaceutiques (MRP) utilisés en TEP/TDM dans de nombreux cancers. Pourtant, l’essor de la TEP/TDM reste régulièrement freiné en France pour des motifs économiques, alors que la différence entre le coût d’une TEP/TDM, comparé à celui d’une autre méthode d’imagerie utilisée en routine pour la même indication, n’est pas si évidente une fois qu’on considère l’impact sur la décision thérapeutique et les dépenses évitées par la révision de diagnostics erronés ou incomplets. Cependant, si tous les examens TEP/TDM sont actuellement remboursés de la même manière quel que soit le MRP utilisé, rendant ainsi leur coût identique de la perspective de l’assurance maladie, leurs coûts de production sont variables pour l’hôpital et constituent un paramètre à intégrer en relation avec la fréquence de l’indication de l’examen.Nous avons comparé plusieurs stratégies disponibles pour l’imagerie du cancer de la prostate en nous basant sur les données acquises pendant l’étude française multicentrique prospective FLUPROSTIC, qui incluait deux MRP pour l’imagerie TEP: la 18F-flurocholine (FCH) et le 18F-fluorure de sodium (FNa), la FCH étant 2 fois plus coûteuse pour l’hôpital que le FNa.L’analyse de l’impact de chaque stratégie d’imagerie sur la décision thérapeutique, basé l’analyse de questionnaires dédiés complétés par les cliniciens référents, a démontré que la TEP/TDM à la FCH était la modalité d’imagerie ayant le plus grand impact, en particulier pour les patients en situation de première récidive biologique.3La comparaison coût-utilité des stratégies d’imagerie, réalisée de la perspective de l’assurance maladie pour les patients en première récidive biologique de cancer de la prostate sur un horizon temporel « à vie », s’est basée sur un modèle combinant un arbre décisionnel intégrant les performances diagnostiques de l’imagerie et un modèle de Markov simulant l’histoire naturelle du cancer de la prostate. Cette analyse a démontré que la TEP/TDM à la FCH, modalité d’imagerie la plus exacte d’un point de vue diagnostique, avait une probabilité de 100% de chance d’être la stratégie la plus coût-utile pour des seuils de volonté à payer de 3000€ ou 9000€ par année de vie pondérée par la qualité gagnée, si l’interprétation de l’imagerie était faite par des médecins spécialistes locaux ou des experts respectivement. De la perspective de l’hôpital, la baisse de 20% du coût de la FCH entre 2018 et 2019 avait permis de rentabiliser la production d’examens TEP/TDM à la FCH fait pour l’imagerie du cancer de la prostate.La TEP/TDM augmente l’exactitude diagnostique et impacte sur la décision thérapeutique dans de nombreux cancers. Elle contribue à diminuer les traitements inutiles ainsi que les effets secondaires potentiels qui leur sont associés, à améliorer la qualité de vie des patients et à diminuer les coûts de prise en charge par le système de santé. L’évaluation médico-économique des MRP utilisés en imagerie TEP/TDM en oncologie semble donc indispensable, en plus de celle de leur performances diagnostiques, afin d’en optimiser l’utilisation. En France, cette évaluation devrait se faire des perspectives de l’assurance maladie et de l’hôpital, pour qui le coût de production d’un examen TEP/TDM peut varier sensiblement en fonction du coût du MRP et constituer un frein à son utilisation, même dans une indication fréquente pour laquelle les performances diagnostiques et l’impact sur la décision thérapeutique sont importants

Medico-economic optimization of PET/CT scans in oncology imaging

Les machines de tomographie par émission de positons couplées à la tomodensitométrie (TEP/TDM) sont devenues incontournables en oncologie. De nombreuses études ont rapporté les performances des différents médicaments radiopharmaceutiques (MRP) utilisés en TEP/TDM dans de nombreux cancers. Pourtant, l’essor de la TEP/TDM reste régulièrement freiné en France pour des motifs économiques, alors que la différence entre le coût d’une TEP/TDM, comparé à celui d’une autre méthode d’imagerie utilisée en routine pour la même indication, n’est pas si évidente une fois qu’on considère l’impact sur la décision thérapeutique et les dépenses évitées par la révision de diagnostics erronés ou incomplets. Cependant, si tous les examens TEP/TDM sont actuellement remboursés de la même manière quel que soit le MRP utilisé, rendant ainsi leur coût identique de la perspective de l’assurance maladie, leurs coûts de production sont variables pour l’hôpital et constituent un paramètre à intégrer en relation avec la fréquence de l’indication de l’examen.Nous avons comparé plusieurs stratégies disponibles pour l’imagerie du cancer de la prostate en nous basant sur les données acquises pendant l’étude française multicentrique prospective FLUPROSTIC, qui incluait deux MRP pour l’imagerie TEP: la 18F-flurocholine (FCH) et le 18F-fluorure de sodium (FNa), la FCH étant 2 fois plus coûteuse pour l’hôpital que le FNa.L’analyse de l’impact de chaque stratégie d’imagerie sur la décision thérapeutique, basé l’analyse de questionnaires dédiés complétés par les cliniciens référents, a démontré que la TEP/TDM à la FCH était la modalité d’imagerie ayant le plus grand impact, en particulier pour les patients en situation de première récidive biologique.3La comparaison coût-utilité des stratégies d’imagerie, réalisée de la perspective de l’assurance maladie pour les patients en première récidive biologique de cancer de la prostate sur un horizon temporel « à vie », s’est basée sur un modèle combinant un arbre décisionnel intégrant les performances diagnostiques de l’imagerie et un modèle de Markov simulant l’histoire naturelle du cancer de la prostate. Cette analyse a démontré que la TEP/TDM à la FCH, modalité d’imagerie la plus exacte d’un point de vue diagnostique, avait une probabilité de 100% de chance d’être la stratégie la plus coût-utile pour des seuils de volonté à payer de 3000€ ou 9000€ par année de vie pondérée par la qualité gagnée, si l’interprétation de l’imagerie était faite par des médecins spécialistes locaux ou des experts respectivement. De la perspective de l’hôpital, la baisse de 20% du coût de la FCH entre 2018 et 2019 avait permis de rentabiliser la production d’examens TEP/TDM à la FCH fait pour l’imagerie du cancer de la prostate.La TEP/TDM augmente l’exactitude diagnostique et impacte sur la décision thérapeutique dans de nombreux cancers. Elle contribue à diminuer les traitements inutiles ainsi que les effets secondaires potentiels qui leur sont associés, à améliorer la qualité de vie des patients et à diminuer les coûts de prise en charge par le système de santé. L’évaluation médico-économique des MRP utilisés en imagerie TEP/TDM en oncologie semble donc indispensable, en plus de celle de leur performances diagnostiques, afin d’en optimiser l’utilisation. En France, cette évaluation devrait se faire des perspectives de l’assurance maladie et de l’hôpital, pour qui le coût de production d’un examen TEP/TDM peut varier sensiblement en fonction du coût du MRP et constituer un frein à son utilisation, même dans une indication fréquente pour laquelle les performances diagnostiques et l’impact sur la décision thérapeutique sont importants.Positron emission tomography coupled with computed tomography (PET/CT) devices are essential pathways in oncology. Many studies have reported the performances of the various radiopharmaceutical drugs (RPD) used for PET/CT imaging in many cancers. The rise of PET/CT remains slowed down in France for economic reasons. However, the difference between the cost of a PET/CT examination, compared to that of another modern imaging routinely used in the same indication, is not so obvious once considered the impact on decision making and the costs avoided by the revision of erroneous or incomplete diagnoses. Nonetheless, if all PET/CT examinations are currently reimbursed in the same way regardless of the RPD used, thus making their cost identical from the health insurance perspective, their production costs for the hospital vary and should be considered according to the frequency of the indication of the examination.We compared several imaging strategies for prostate cancer imaging by analyzing the data acquired during the French prospective multicenter FLUPROSTIC study, which included two RPD for PET imaging: 18F-flurocholine (FCH) and 18F-sodium fluoride (NaF), FCH being twice more costly for the hospital than NaF.The analysis of the impact of each imaging strategy on decision making, based on dedicated questionnaires completed by the referring clinicians, demonstrated that FCH PET/CT was the imaging modality that had the highest impact, especially for patients presenting with first biochemical recurrence.The cost-utility analysis, carried out from the health insurance perspective for patients with first biochemical recurrence of prostate cancer over a "lifetime" time horizon, was based on a model5combining a decision tree integrating the diagnostic performances of imaging and a Markov model simulating the natural history of prostate cancer. This analysis demonstrated that FCH PET/CT, the most accurate imaging modality from a diagnostic point of view, had a 100% probability of being the most cost-effective strategy for willingness to pay thresholds of 3,000€ or 9,000€ per quality-adjusted life year gained if the imaging reading was made by local specialists or experts respectively. From the hospital perspective, the 20% drop in the cost of FCH between 2018 and 2019 had made profitable the production of FCH PET/CT examinations for prostate cancer imaging.PET/CT increases diagnostic accuracy and has an impact on decision making in many cancers. It helps to reduce unnecessary treatments and their potential side effects, to improve the quality of life of patients and to reduce the treatment costs for the health care system. The medico-economic evaluation of RPDs used for PET/CT imaging in oncology, in addition to that of their diagnostic performances, seems essential in order to optimize their use. In France, this evaluation should be made from both perspectives of the health insurance and the hospital. Indeed, the PET/CT production costs can largely vary for the hospital according to the RPD costs and constitute a barrier to its use, even in a frequent indication for which diagnostic performances and impact on decision making are high

Thyroid Incidentaloma on 18F-fluorocholine PET/CT and 68Ga-PSMA PET/CT Revealing a Medullary Thyroid Carcinoma

International audienceA 66-year-old man with prostate cancer underwent F-fluorocholine PET/CT and thereafter Ga-labeled prostate-specific membrane antigen PET/CT to explore a rising prostate-specific antigen level. Both PET/CT studies showed a thyroid incidentaloma of the right lobe. Neck ultrasound confirmed the presence of a 16-mm right thyroid nodule. The serum calcitonin level was moderately increased at 25 ng/mL (<10). Cytology was non-diagnostic (Bethesda I). A right lobectomy was performed and pathology revealed a 15-mm medullary thyroid cancer. Two months after surgery, the calcitonin level returned to normal at 3.3 ng/mL

68Ga-PSMA-11 PET/CT in restaging castration-resistant nonmetastatic prostate cancer: detection rate, impact on patients’ disease management and adequacy of impact

International audienceAbstract We aimed to evaluate the impact of prostate-specific membrane antigen ligand labelled with gallium-68 (PSMA-11) PET/CT in restaging patients with castration-resistant nonmetastatic prostate cancer (PCa). Thirty patients were included. At least one malignant focus was found in 27/30 patients (90%). The PSMA-11 PET/CT positivity rate in patients whose prostate-specific antigen serum level (PSA) was greater than 2 ng/ml was 100% (20/20), significantly superior to that of patients whose PSA was less than 2 ng/ml (7/10 = 70%). Six patients (20%) were categorized as oligometastatic (≤3 metastatic foci). Based on the 17 patients for whom a standard of truth was feasible, the overall sensitivity and specificity of PSMA-11 PET/CT in detecting residual disease in castration-resistant PCa patients were 87% and 100% respectively. PSMA-11 PET/CT impacted patients’ disease management in 70% of cases, 60% of case when PSA was less than 2 ng/ml. This management was considered as adequate in 91% of patients. PSMA-11 PET/CT appeared to be effective in restaging patients with castration-resistant nonmetastatic PCa. PSMA-11 PET/CT should be considered as a replacement for bone scans under these conditions

Pituitary Adenoma Recurrence Suspected on Central Hyperthyroidism Despite Empty Sella and Confirmed by 68Ga-DOTA-TOC PET/CT

Thyrotropin-secreting pituitary adenomas are very rare tumors, known to present overexpression of somatostatin receptor subtype 2 and which may consequently demonstrate abnormal uptake on Ga-DOTA-TOC PET/CT. A 67-year-old woman with a history of operated pituitary macroadenoma presented with symptoms of hyperthyroidism including a large goiter. Her serum thyroid hormone levels were in favor of central hyperthyroidism. Pituitary MRI depicted an empty sella but visualized an ambiguous lesion centered on the left sphenoidal sinus. Complementary Ga-DOTA-TOC PET/CT finally demonstrated intense uptake by the sphenoidal lesion, confirming recurrence of the pituitary adenoma

Prognostic value of serum CYFRA 21-1 1 in patients with anal canal squamous cell carcinoma treated with radio(chemo)therapy

Abstract Background We aimed to assess the prognostic value of CYFRA 21-1 in a series of patients with anal canal squamous cell carcinoma treated by radiation-based therapy. Methods All patients with anal cancer referred between September 2005 and July 2013 were considered. Patients with diagnosis of anal squamous cell carcinoma and in whom pre- and post-treatment serum CYFRA 21-1 levels were available were included. Serum CYFRA 21-1 levels at initial workup and after therapy were collected. Survival rates were estimated using the Kaplan–Meier method. Cox regression analysis was used to evaluate prognostic variables for prediction of outcomes. Results Eighty-two patients were included. Median follow-up was 60 months (range: 8–128). Pre-treatment serum CYFRA 21-1 levels were significantly correlated with tumour stage (p < 0.001). Normal post-treatment serum CYFRA 21-1 level was significantly correlated with tumour complete response (p = 0.004). Elevated post-treatment serum CYFRA 21-1 level was significantly associated with poorer progression-free survival (p = 0.02) and overall survival (p = 0.003). T stage and post-treatment serum CYFRA 21-1 were independent prognostic factors for overall survival (p = 0.04 and 0.03, respectively). Conclusions Serum CYFRA 21-1 appears to be a useful marker for the monitoring of anal squamous cell carcinoma patients. Elevated post-treatment value appears to be correlated with treatment failure

Comparison of F-sodium fluoride PET/CT, F-fluorocholine PET/CT and diffusion-weighted MRI for the detection of bone metastases in recurrent prostate cancer: a cost-effectiveness analysis in France.

BACKGROUND: The diagnostic performance of 18F-sodium fluoride positron emission tomography/computed tomography (PET/CT) (NaF), 18F-fluorocholine PET/CT (FCH) and diffusion-weighted whole-body magnetic resonance imaging (DW-MRI) in detecting bone metastases in prostate cancer (PCa) patients with first biochemical recurrence (BCR) has already been published, but their cost-effectiveness in this indication have never been compared. METHODS: We performed trial-based and model-based economic evaluations. In the trial, PCa patients with first BCR after previous definitive treatment were prospectively included. Imaging readings were performed both on-site by local specialists and centrally by experts. The economic evaluation extrapolated the diagnostic performances of the imaging techniques using a combination of a decision tree and Markov model based on the natural history of PCa. The health states were non-metastatic and metastatic BCR, non-metastatic and metastatic castration-resistant prostate cancer and death. The state-transition probabilities and utilities associated with each health state were derived from the literature. Real costs were extracted from the National Cost Study of hospital costs and the social health insurance cost schedule. RESULTS: There was no significant difference in diagnostic performance among the 3 imaging modalities in detecting bone metastases. FCH was the most cost-effective imaging modality above a threshold incremental cost-effectiveness ratio of 3000€/QALY when imaging was interpreted by local specialists and 9000€/QALY when imaging was interpreted by experts. CONCLUSIONS: FCH had a better incremental effect on QALY, independent of imaging reading and should be preferred for detecting bone metastases in patients with biochemical recurrence of prostate cancer. TRIAL REGISTRATION: NCT01501630. Registered 29 December 2011