High-Cost Surveillance Imaging Falls Short on Survival Benefit in DLBCL

Surveillance imaging to monitor patients with diffuse large B-cell lymphoma (DLBCL) in first remission may be common practice, but a new cost-effectiveness analysis has found that this type of surveillance is costly while offering little clinical benefit.

According to the findings in a study by Scott Huntington, MD, from the University of Pennsylvania, and colleagues, there was negligible benefit associated with the use of either computed tomography (CT) scans or positron emission tomography–computed tomography (PET/CT) scans during the first two years after remission, compared with clinical follow-up without routine imaging.

In their cost-effectiveness analysis, Dr. Huntington and his team used a decision-analytic Markov model that allowed them to compare three different strategies for asymptomatic patients with complete response following primary treatment for DLCBL:

  • Follow-up including biannual CT scans for two years (estimated cost over 2 years = $38)
  • Follow-up including biannual PET/CT scans for two years
  • Routine clinical follow-up including physical exams, serial history, and surveillance laboratory evaluations

According to the investigators, two years of routine CT and PET/CT scans yielded only 0.03 life-years gained and 0.04 life-years gained, respectively, compared with the routine follow-up group.

The survival benefit remained small when investigators adjusted for quality (0.020 quality-adjusted life years [QALYs] for the CT group and 0.025 for the PET/CT group). QALY is a generic measure used to assess the value of a medical intervention, based on the number of years of life that would be added by the intervention – taking into account the treatment’s impact on both the quality and quantity of a patient’s life.

This small survival benefit came at a substantial cost: $41,950 for CT plus clinical follow-up; $42,550 for PET/CT plus clinical follow-up; and $38,280 for clinical follow-up alone.

The incremental cost-effectiveness ratios were $164,960 per QALY for CT scans and $168,750 per QALY for PET/CT scans when compared with routine clinical follow-up.

“Our findings question the role of routine surveillance imaging in this clinical setting and align with the recent position outlined in the American Society of Hematology’s Choosing Wisely campaign,” Dr. Huntington told ASH Clinical News. In their Choosing Wisely campaigns, both ASH and the American Society of Clinical Oncology have recommended limiting surveillance imaging in asymptomatic patients who were treated with a curative intent.

Using health-state transition probabilities from the randomized, controlled CORAL study, they were able to predict patient outcomes.

“Despite the use of conservative model estimates that associate early imaging-detected relapse with better patient outcomes, our analysis found routine surveillance imaging to be associated with substantial health-care costs, but little clinical utility,” Dr. Huntington said.

As a provider, Dr. Huntington himself has changed his recommended surveillance strategy from routine imaging to non–imaging-based clinical follow-up. “It has been helpful to discuss the risks and/or benefits of serial imaging with patients and encourage active engagement in their ongoing clinical surveillance,” he said.

Commenting on the study’s findings in an accompanying editorial, Gregory A. Abel, MD, MPH, of the Dana-Farber Cancer Institute, wrote that the medical community must also consider comparative-effectiveness data and clinical data when interpreting findings from a cost-effective analysis. However, he noted that the analysis by Dr. Huntington and his colleagues does suggest such surveillance is ineffective.

“Importantly, for certain populations at higher risk for relapse (such as those with double-hit lymphoma), it may still be reasonable,” Dr. Abel wrote in the editorial. “Moreover, given patient and physician concerns regarding detecting relapse, it seems unlikely we will eliminate all surveillance imaging until we have something to replace it with. One promising candidate is peripheral-blood assessment for minimal residual disease.”


References

  • Huntington SF, Svoboda J, Doshi JA. Cost-effectiveness analysis of routine surveillance imaging of patients with diffuse large B-cell lymphoma in first remission. J Clin Oncol. 2015 March 30. [Epub ahead of print]
  • Abel GA. Does surveillance imaging after treatment for diffuse large B-cell lymphoma really work? J Clin Oncol. 2015 March 30. [Epub ahead of print]

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