The efficacy of PET staging for small-cell lung cancer: a systematic review and cost analysis in the Australian setting.

Introduction: This study aimed to establish from the published literature the efficacy of a positron emission tomography (PET)-based strategy for the staging of small-cell lung cancer compared to conventional methods, the potential impact on patient management and outcomes, and cost implications for the Australian health system.

Methods: EMBASE, Current Contents, PubMed, and OVID, databases were searched using relevant search terms. Reference lists of identified studies were examined for additional pertinent papers. Literature review identified 22 relevant studies containing data for 1663 patients. Studies were evaluated regarding the adequacy of pathological or clinical correlation of imaging findings. Efficacy of PET-staging was analyzed. The Medicare benefits schedule was used to compare costs of the two strategies.

Results: Published data confirm that PET staging has a sensitivity approaching 100% and specificity exceeding 90%. Data suggest that compared to conventional staging, PET can alter management (including radiotherapy portal changes) in at least 28% of patients, can result in the addition of life-prolonging radiotherapy in 6%, and avert unnecessary radiotherapy with associated toxicity in 9%. PET-based staging costs 1603 Australian dollars (AUD) and conventional staging 1610 AUD per patient. An additional 540,354 AUD may be saved annually through avoidance of unnecessary radiotherapy.

Conclusions: PET-based staging seems superior to conventional staging, and can significantly alter patient management particularly with regard to the inclusion, omission, and portal design of radiotherapy. The initial costs of the two strategies do not seem significantly different. PET may ultimately reduce healthcare costs through avoidance of inappropriate thoracic radiotherapy. The major advantages of PET-staging may, however, lie in averting unnecessary toxicity and in the appropriate addition of thoracic radiotherapy with potential survival gains.