Use of 18F-FDG PET/CT as an Initial Staging Procedure for Stage II–III Breast Cancer: A Multicenter Value Analysis

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  • 1 University of California, San Francisco, San Francisco, California;
  • 2 University of Minnesota, Minneapolis, Minnesota;
  • 3 Georgetown University, Washington, DC;
  • 4 University of Alabama at Birmingham, Birmingham, Alabama; and
  • 5 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.
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Background: Metastatic staging imaging is not recommended for asymptomatic patients with stage I–II breast cancer. Greater distant metastatic disease risk may warrant baseline imaging in patients with stage II–III with high-risk biologic subtypes. NCCN Guidelines recommend considering CT of the chest, abdomen, and pelvis (CT CAP) and bone scan in appropriate patients. CT CAP and bone scan are considered standard of care (SoC), although PET/CT is a patient-centered alternative. Methods: Data were available for 799 high-risk patients with clinical stage II–III disease who initiated screening for the I-SPY2 trial at 4 institutions. A total of 564 complete records were reviewed to compare PET/CT versus SoC. Costs were determined from the payer perspective using the national 2018 Medicare Physician Fee Schedule and representative reimbursements to the University of California, San Francisco (UCSF). Incremental cost-effectiveness ratio (ICER) measured cost of using PET/CT per percent of patients who avoided a false-positive (FP). Results: The de novo metastatic disease rate was 4.6%. Imaging varied across the 4 institutions (P<.0001). The FP rate was higher using SoC versus PET/CT (22.1% vs 11.1%; P=.0009). Mean time between incidental finding on baseline imaging to FP determination was 10.8 days. Mean time from diagnosis to chemotherapy initiation was 44.3 days with SoC versus 37.5 days with PET/CT (P=.0001). Mean cost per patient was $1,132 (SoC) versus $1,477 (PET/CT) using the Medicare Physician Fee Schedule, with an ICER of $31. Using representative reimbursements to UCSF, mean cost per patient was $1,236 (SoC) versus $1,073 (PET/CT) for Medicare, and $3,083 (SoC) versus $1,656 (PET/CT) for a private payer, with ICERs of −$15 and −$130, respectively. Conclusions: Considerable variation exists in metastatic staging practices. PET/CT reduced FP risk by half and decreased workup of incidental findings, allowing for earlier treatment start. PET/CT may be cost-effective, and at one institution was shown to be cost-saving. Better alignment is needed between hospital pricing strategies and payer coverage policies to deliver high-value care.

Submitted September 20, 2019; accepted for publication May 25, 2020.

Author contributions: Study concept and design: Hyland, Varghese, Hirst, Esserman, Melisko. Data acquisition: Hyland, Beckwith, Khoury, Varnado. Cost analysis: Hyland, Varghese. Statistical analysis: Yau. Manuscript preparation: Hyland, Flavell, Esserman, Melisko. Critical revision: Chien, Yee, Isaacs, Forero-Torres, Esserman, Melisko.

Disclosures: Dr. Isaacs has disclosed that she is a consultant for PUMA, Seattle Genetics, Sanofi, Novartis, and Genentech. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This work was supported by funding from Quantum Leap Healthcare Collaborative.

Correspondence: Michelle E. Melisko, MD, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, 1825 4th Street, San Francisco, CA 94158. Email: michelle.melisko@ucsf.edu

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