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Auguste P, Barton P, Hyde C, et al. An Economic Evaluation of Positron Emission Tomography (PET) and Positron Emission Tomography/Computed Tomography (PET/CT) for the Diagnosis of Breast Cancer Recurrence. Southampton (UK): NIHR Journals Library; 2011 Apr. (Health Technology Assessment, No. 15.18.)
An Economic Evaluation of Positron Emission Tomography (PET) and Positron Emission Tomography/Computed Tomography (PET/CT) for the Diagnosis of Breast Cancer Recurrence.
Show detailsAppendix 2.1. Assumptions from NICE (2009) guidelines
Here we present the assumptions regarding the study population, treatment and survival used by NICE in its economic evaluation. The most cost-effective strategy was used as the basis of the treatment cost presented in Table 2.
TABLE 7Model assumptions used in the NICE 2009 report24
| Assumptions |
|---|
| Study population Women with metastatic breast cancer who had previously been treated with anthracycline (treatment may have been used as adjuvant treatment) Patients in whom the disease is hormone responsive will receive alternative/additional treatment |
| Treatment Patients will receive first-line therapy; there is the possibility of the patient dying from a toxic death. The assumption is that a toxic death can only occur after first-line therapy There is a time lag of one month between discontinuing first-line therapy and commencing second-line therapy. In the absence of toxicity the patient will continue first-line therapy. At this point it is assumed that response can be assessed, to the patient faces a probability of responding to therapy, or having stable disease or not Capecitabine used as first-line treatment or part of a combination of first-line treatment will not be used in second-line treatment The ‘no chemotherapy’ treatment would result in no progression-free survival and 5 months' survival with progressive disease |
| Survival Overall survival was assumed to be time to progression of first-line treatment, time to progression of second-line treatment, time to progression of third-line treatment and progression to death (5 months) Survival and time to progression followed exponential distributions Authors assumed the utility with progressive disease, 0.45 Utility associated with stable disease, 0.65 Utility associated with progressive disease, 0.45 |
| Cost estimation For treatment which required a combination of two drugs, it was assumed that there will be one administration cost At the beginning of each cycle, it was assumed that the patient will have an oncologist consultation |
We used strategy 14, the most cost-effective strategy, which leads to an expected mean cost of £18,118, which we inflated to 2008 prices.
Appendix 2.2. Accuracy data for conventional work-up, positron emission tomography and positron emission tomography/computed tomography
TABLE 8Patient data: direct and indirect comparisons of the sensitivity and specificity of PET compared with CITs
| Comparison | PET sensitivity, % (95% CI) | CIT sensitivity, % (95% CI) | Relative sensitivity (95% CI) | PET specificity, % (95% CI) | CIT specificity, % (95% CI) | Relative specificity (95% CI) |
|---|---|---|---|---|---|---|
| Direct PET vs CIT | 89 (83 to 93), n = 10 | 79 (72 to 85), n = 10 | 1.12 (1.04 to 1.21), p = 0.005 | 93 (83 to 97) | 83 (67 to 92) | 1.12 (1.01 to 1.24), p = 0.036 |
| Indirect PET vs CIT | 91 (87 to 93), n = 25 | 81 (73 to 87), n = 11 | 1.12 (1.04 to 1.21), p = 0.005 | 86 (79 to 91) | 73 (59 to 83) | 1.18 (1.03 to 1.36), p = 0.017 |
Reproduced from Pennant et al.17
TABLE 9Patient data: direct comparison of the sensitivity and specificity of PET/CT compared with CT and indirect comparison of PET/CT compared with a range of CITs
| Comparison | PET/CTsensitivity, % (95% CI) | CIT sensitivity, % (95% CI) | Relative sensitivity (95% CI) | PET/CTspecificity, % (95% CI) | CIT specificity, % (95% CI) | Relative specificity (95% CI) |
|---|---|---|---|---|---|---|
| Direct PET/CT vs CT | 95 (88 to 98), n = 4 | 80 (65 to 90), n = 4 | 1.19 (1.03 to 1.37), p = 0.015 | 89 (69 to 97) | 77 (50 to 92) | 1.15 (0.95 to 1.41), p = 0.157 |
| Indirect PET/CT vs CIT | 95 (89 to 97), n = 5 | 78 (72 to 84), n = 11 | 1.21 (1.11 to 1.31), p < 0.0001 | 89 (76 to 96) | 79 (65 to 88) | 1.13 (0.99 to 1.29), p = 0.063 |
Reproduced from Pennant et al.17
Appendix 2.3. Beta and normal distributions for accuracy, prevalence, treatment and expected quality-adjusted life-years
Beta distributions
TABLE 10Probability distribution of the sensitivities by strategy
| Strategy | Base-case sensitivities | Range (95% CI) | Probability distribution | Source |
|---|---|---|---|---|
| Conventional work-up | 0.80 | 0.72 to 0.87 | Beta (85.6, 21.4) | Derived from data presented in Pennant et al.17 |
| PET | 0.91 | 0.87 to 0.93 | Beta (282.1, 27.9) | Derived from data presented in Pennant et al.17 |
| PET/CT | 0.95 | 0.89 to 0.97 | Beta (71.25, 3.75) | Derived from data presented in Pennant et al.17 |
| PET together with conventional work-up | 0.99 | 0.97 to 1.00 | Beta (168.3, 1.7) | Derived from data presented in Pennant et al.17 |
TABLE 11Probability distribution of the specificities by strategy
| Strategy | Base-case specificities | Range (95% CI) | Probability distribution | Source |
|---|---|---|---|---|
| Conventional work-up | 0.76 | 0.59 to 0.88 | Beta (20.52,6.48) | Derived from data presented in Pennant et al.17 |
| PET | 0.86 | 0.79 to 0.91 | Beta (103.2, 16.8) | Derived from data presented in Pennant et al.17 |
| PET/CT | 0.89 | 0.76 to 0.96 | Beta (27.145, 3.355) | Derived from data presented in Pennant et al.17 |
| PET together with conventional work-up | 0.68 | 0.45 to 0.89 | Beta (12.24, 5.76) | Derived from data presented in Pennant et al.17 |
TABLE 12Probability distribution of the prevalence
| Base-case prevalence | Range (95% CI) | Probability distribution | Source | |
|---|---|---|---|---|
| Prevalence | 0.69 | 0.66 to 0.72 | Beta (655.5, 294.5) | Derived from data presented in Pennant et al.17 |
Normal distributions
TABLE 13Normal distribution for parameter (treatment)
TABLE 14Normal distribution for parameter (QALYs expected for treatment)
| QALY | Probability distribution | Standard deviation | Source | |
|---|---|---|---|---|
| Total QALYs expected for treatment | 0.8737 | Normal | 0.08737 | NICE24 |
Appendix 2.4. Detailed results of the sensitivity analysis
1(a) Increasing the sensitivity of PET/CT to 97% – all other parameters as base case (cost per QALY)
TABLE 15aIncreasing the sensitivity of PET/CT to 97% – all other parameters as base case (cost per QALY)
| Strategy | Mean cost per strategy | Difference in costs | Effectiveness (QALY) | Incremental QALYs | ICER |
|---|---|---|---|---|---|
| Conventional work-up | £10,862 | – | 4.7827 | – | – |
| PET | £12,805 | £1942 | 4.8490 | 0.0663 | £29,300 |
| PET/CT | £13,811 | £1006 | 4.8852 | 0.0362 | £27,800 |
| PET/CT as an adjunct to conventional work-up | £14,616 | £805 | 4.8997 | 0.0145 | £55,600 |
1(b) Increasing the specificity of PET/CT to 100% – all other parameters as base case (cost per QALY)
TABLE 15bIncreasing the specificity of PET/CT to 100% – all other parameters as base case (cost per QALY)
| Strategy | Mean cost per strategy | Difference in costs | Effectiveness (QALY) | Incremental QALYs | ICER |
|---|---|---|---|---|---|
| Conventional work-up | £10,862 | – | 4.7827 | – | – |
| PET | £12,805 | £1942 | 4.8490 | 0.0663 | £29,300 |
| PET/CT | £13,547 | £742 | 4.8732 | 0.0241 | £30,800 |
| PET/CT as an adjunct to conventional work-up | £14,561 | £1014 | 4.8973 | 0.0241 | £42,000 |
1(c) Reducing the cost of the PET/CT strategy from the base-case value of £1236 to £1210
TABLE 15cReducing the cost of the PET/CT strategy from the base-case value of £1236 to £1210
| Strategy | Mean cost per strategy | Difference in costs | Effectiveness (QALY) | Incremental QALYs | ICER |
|---|---|---|---|---|---|
| Conventional work-up | £10,862 | – | 4.7827 | – | – |
| PET | £12,805 | £1942 | 4.8490 | 0.0663 | £29,300 |
| PET/CT | £13,526 | £721 | 4.8732 | 0.0241 | £29,900 |
| PET/CT as an adjunct to conventional work-up | £14,564 | 1038 | 4.8973 | 0.0241 | £43,100 |
2(a) Reducing the prevalence to the lowest value in range (0.19)
TABLE 16aSensitivity analysis results for cost per QALY (2007–8 prices)
| Strategy | Mean cost per strategy | Difference in costs | Effectiveness (QALY) | Incremental QALYs | ICER |
|---|---|---|---|---|---|
| Conventional work-up | £3368 | – | 11.3694 | – | – |
| PET | £4270 | £902 | 11.3877 | 0.0183 | £49,400 |
| PET/CT | £4639 | £369 | 11.3943 | 0.0066 | £55,600 |
| PET/CT as an adjunct to conventional work-up | £5291 | £652 | 11.4010 | 0.0066 | £98,200 |
2(b) Increasing the prevalence to the highest value in the range (0.93)
TABLE 16bSensitivity analysis results for cost per QALY (2007–8) prices
| Strategy | Mean cost per strategy | Difference in costs | Effectiveness (QALY) | Incremental QALYs | ICER |
|---|---|---|---|---|---|
| Conventional work-up | £14,463 | – | 1.6211 | – | – |
| PET | £16,904 | £2442 | 1.7105 | 0.0894 | £27,300 |
| PET/CT | £17,833 | £928 | 1.743 | 0.0325 | £28,600 |
| PET/CT as an adjunct to conventional work-up | £19,018 | £1185 | 1.7755 | 0.0325 | £36,500 |
3. Using specificity from just one (conventional work-up) of the two combined tests for PET/CT as an adjunct to conventional work-up
TABLE 17Base-case results from the analysis cost per QALY (2007–8 prices)
| Strategy | Mean cost per strategy | Difference in costs | Effectiveness (QALY) | Incremental QALYs | ICER |
|---|---|---|---|---|---|
| Conventional work-up | £10,864 | – | 4.7827 | – | – |
| PET | £12,807 | £1942 | 4.8490 | 0.0663 | £29,300 |
| PET/CT | £13,554 | £747 | 4.8732 | 0.0241 | £31,000 |
| PET/CT together with conventional work-up | £14,563 | £1009 | 4.8973 | 0.0241 | £42,000 |
4. Omitting PET alone as a strategy
TABLE 18Base-case results from the analysis cost per QALY (2007–8 prices)
| Strategy | Mean cost per strategy | Difference in costs | Effectiveness (QALY) | Incremental QALYs | ICER |
|---|---|---|---|---|---|
| Conventional work-up | £10,864 | – | 4.7827 | – | – |
| PET/CT | £13,554 | £2690 | 4.8732 | 0.0905 | £29,700 |
| PET/CT together with conventional work-up | £14,563 | £1009 | 4.8973 | 0.0241 | £41,900 |
- Assumptions from NICE (2009) guidelines
- Accuracy data for conventional work-up, positron emission tomography and positron emission tomography/computed tomography
- Beta and normal distributions for accuracy, prevalence, treatment and expected quality-adjusted life-years
- Detailed results of the sensitivity analysis
- Model-based assumptions - An Economic Evaluation of Positron Emission Tomography...Model-based assumptions - An Economic Evaluation of Positron Emission Tomography (PET) and Positron Emission Tomography/Computed Tomography (PET/CT) for the Diagnosis of Breast Cancer Recurrence
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