PET-CT surveillance for advanced head and neck cancer: a cost-effective alternative to planned neck dissection?

Background

Despite controversy, planned neck dissection (ND) remains standard treatment for patients with locally advanced head and neck squamous cell carcinoma after radical chemo-radiotherapy. FDG-PET-CT scanning has demonstrated high negative predictive values for persistent disease, and could thereby enable low risk patients to be spared from unnecessary surgery. Evidence of the cost-effectiveness of PET-CT surveillance strategies is limited however, and no evaluations have yet been conducted from a UK perspective.

Methods

An economic evaluation was conducted to assess the lifetime cost-effectiveness of PET-CT surveillance versus planned ND from a UK secondary care perspective. Cost and health outcomes associated with the initial 6-month treatment period (CRT +/- ND) were derived from individual data on 564 patients from a recent UK multicentre randomised controlled trial (PET-Neck). Subsequent outcomes were derived using a constructed Markov model to track patients through four health states: disease-free, local recurrence, distant recurrence and dead. Model inputs were derived from trial data and literature sources.

Results

PET-CT surveillance results in a lifetime cost saving of -£1,485 (95% CI: -2,815 to 159) and health gain of +0.13 (95% CI: -0.49 to +0.79) quality-adjusted life-years (QALYs) per patient. The intervention therefore dominates standard care, being more effective and less costly, with an incremental net benefit (INB) of +0.21 QALYs (95% CI: -0.41 to +0.85). At a willingness-to-pay per QALY threshold of £20,000, PET-CT is associated with a 75% probability of being cost-effective, dropping to 68% at a £100,000/QALY threshold. The intervention remained cost-effective when considering a broader NHS and personal social services perspective; however, uncertainty around the mean cost-effectiveness values was wide.

Conclusions

PET-CT surveillance appears to be cost-effective, leading to expected lifetime cost savings and a marginal health increment. There is significant uncertainty in the longer term which may warrant additional survivor-ship research.

Clinical trial identification

ISRCTN 13735240

Legal entity responsible for the study

Warwick Medical School.

Funding

National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme (project number 06/302/129).

Disclosure

All authors have declared no conflicts of interest.