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Managing incidental pancreatic cystic neoplasms with integrated molecular pathology is a cost-effective strategy.

Das A, Brugge W, Mishra G, Smith DM, Sachdev M, Ellsworth E - Endosc Int Open (2015)

Bottom Line: Quality-adjusted life-years (QALY), relative risk with 95 %CI, Number Needed to Treat (NNT), and incremental cost-effectiveness ratios were calculated.Relative risk of malignancy compared to the current standard of care and nearest competing strategy, Strategy III, was 0.18 (95 %CI 0.06 - 0.53) with an NNT of 56 (95 %CI 34 - 120).Use of IMP was the most cost-effective strategy, supporting its routine clinical use.

View Article: PubMed Central - PubMed

Affiliation: Arizona Center for Digestive Health, Gilbert, Arizona, United States.

ABSTRACT

Background and study aims: Current guidelines recommend using endoscopic ultrasound (EUS), carcinoembryonic antigen (CEA) testing and cytology to manage incidental pancreatic cystic neoplasms (PCN); however, studies suggest a strategy including integrated molecular pathology (IMP) of cyst fluid may further aid in predicting risk of malignancy. Here, we evaluate several strategies for diagnosing and managing asymptomatic PCN using healthcare economic modeling.

Patients and methods: A third-party-payer perspective Markov decision model examined four management strategies in a hypothetical cohort of 1000 asymptomatic patients incidentally found to have a 3 cm solitary pancreatic cystic lesion. Strategy I used cross-sectional imaging, recommended surgery only if symptoms or risk factors emerged. Strategy II considered patients for resection without initial EUS. Strategy III (EUS + CEA + Cytology) referred only those with mucinous cysts (CEA > 192 ng/mL) for resection. Strategy IV implemented IMP; a commercially available panel provided a "Benign," "Mucinous," or "Aggressive" classification based on the level of mutational change in cyst fluid. "Benign" and "Mucinous" patients were followed with surveillance; "Aggressive" patients were referred for resection. Quality-adjusted life-years (QALY), relative risk with 95 %CI, Number Needed to Treat (NNT), and incremental cost-effectiveness ratios were calculated.

Results: Strategy IV provided the greatest increase in QALY at nearly identical cost to the cheapest approach, Strategy I. Relative risk of malignancy compared to the current standard of care and nearest competing strategy, Strategy III, was 0.18 (95 %CI 0.06 - 0.53) with an NNT of 56 (95 %CI 34 - 120).

Conclusions: Use of IMP was the most cost-effective strategy, supporting its routine clinical use.

No MeSH data available.


Related in: MedlinePlus

Results of two-way model sensitivity analysis comparing ranges of cost of integrated mutational profiling (X-axis) vs. diagnostic sensitivity of the PathFinder TG assay in differentiating mucinous from non-mucinous PCNs. For most possible costs and sensitivities, PFTG strategy is preferred (green), except where the cost of PFTG is too high (blue). b Results of two-way sensitivity analysis comparing ranges of sensitivity of PathFinder TG vs. sensitivity of CEA in differentiating mucinous from non-mucinous cysts. PFTG is preferred except in areas marked by blue (low sensitivity of PFTG and relatively high CEA sensitivity). For reference, a ‘star’ designates the baseline estimates in each nomogram.
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FI179-2: Results of two-way model sensitivity analysis comparing ranges of cost of integrated mutational profiling (X-axis) vs. diagnostic sensitivity of the PathFinder TG assay in differentiating mucinous from non-mucinous PCNs. For most possible costs and sensitivities, PFTG strategy is preferred (green), except where the cost of PFTG is too high (blue). b Results of two-way sensitivity analysis comparing ranges of sensitivity of PathFinder TG vs. sensitivity of CEA in differentiating mucinous from non-mucinous cysts. PFTG is preferred except in areas marked by blue (low sensitivity of PFTG and relatively high CEA sensitivity). For reference, a ‘star’ designates the baseline estimates in each nomogram.

Mentions: Because the cost of IMP and the performance characteristics of CEA analysis and IMP are likely to be inter-related determinants of the outcomes of the model, we looked at two-way sensitivity analyses by simultaneously varying these probabilities. Fig.  2 and  Fig. 3 show that even when these variables are varied over a broad range of estimates, IMP remains the preferred management method.


Managing incidental pancreatic cystic neoplasms with integrated molecular pathology is a cost-effective strategy.

Das A, Brugge W, Mishra G, Smith DM, Sachdev M, Ellsworth E - Endosc Int Open (2015)

Results of two-way model sensitivity analysis comparing ranges of cost of integrated mutational profiling (X-axis) vs. diagnostic sensitivity of the PathFinder TG assay in differentiating mucinous from non-mucinous PCNs. For most possible costs and sensitivities, PFTG strategy is preferred (green), except where the cost of PFTG is too high (blue). b Results of two-way sensitivity analysis comparing ranges of sensitivity of PathFinder TG vs. sensitivity of CEA in differentiating mucinous from non-mucinous cysts. PFTG is preferred except in areas marked by blue (low sensitivity of PFTG and relatively high CEA sensitivity). For reference, a ‘star’ designates the baseline estimates in each nomogram.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4612224&req=5

FI179-2: Results of two-way model sensitivity analysis comparing ranges of cost of integrated mutational profiling (X-axis) vs. diagnostic sensitivity of the PathFinder TG assay in differentiating mucinous from non-mucinous PCNs. For most possible costs and sensitivities, PFTG strategy is preferred (green), except where the cost of PFTG is too high (blue). b Results of two-way sensitivity analysis comparing ranges of sensitivity of PathFinder TG vs. sensitivity of CEA in differentiating mucinous from non-mucinous cysts. PFTG is preferred except in areas marked by blue (low sensitivity of PFTG and relatively high CEA sensitivity). For reference, a ‘star’ designates the baseline estimates in each nomogram.
Mentions: Because the cost of IMP and the performance characteristics of CEA analysis and IMP are likely to be inter-related determinants of the outcomes of the model, we looked at two-way sensitivity analyses by simultaneously varying these probabilities. Fig.  2 and  Fig. 3 show that even when these variables are varied over a broad range of estimates, IMP remains the preferred management method.

Bottom Line: Quality-adjusted life-years (QALY), relative risk with 95 %CI, Number Needed to Treat (NNT), and incremental cost-effectiveness ratios were calculated.Relative risk of malignancy compared to the current standard of care and nearest competing strategy, Strategy III, was 0.18 (95 %CI 0.06 - 0.53) with an NNT of 56 (95 %CI 34 - 120).Use of IMP was the most cost-effective strategy, supporting its routine clinical use.

View Article: PubMed Central - PubMed

Affiliation: Arizona Center for Digestive Health, Gilbert, Arizona, United States.

ABSTRACT

Background and study aims: Current guidelines recommend using endoscopic ultrasound (EUS), carcinoembryonic antigen (CEA) testing and cytology to manage incidental pancreatic cystic neoplasms (PCN); however, studies suggest a strategy including integrated molecular pathology (IMP) of cyst fluid may further aid in predicting risk of malignancy. Here, we evaluate several strategies for diagnosing and managing asymptomatic PCN using healthcare economic modeling.

Patients and methods: A third-party-payer perspective Markov decision model examined four management strategies in a hypothetical cohort of 1000 asymptomatic patients incidentally found to have a 3 cm solitary pancreatic cystic lesion. Strategy I used cross-sectional imaging, recommended surgery only if symptoms or risk factors emerged. Strategy II considered patients for resection without initial EUS. Strategy III (EUS + CEA + Cytology) referred only those with mucinous cysts (CEA > 192 ng/mL) for resection. Strategy IV implemented IMP; a commercially available panel provided a "Benign," "Mucinous," or "Aggressive" classification based on the level of mutational change in cyst fluid. "Benign" and "Mucinous" patients were followed with surveillance; "Aggressive" patients were referred for resection. Quality-adjusted life-years (QALY), relative risk with 95 %CI, Number Needed to Treat (NNT), and incremental cost-effectiveness ratios were calculated.

Results: Strategy IV provided the greatest increase in QALY at nearly identical cost to the cheapest approach, Strategy I. Relative risk of malignancy compared to the current standard of care and nearest competing strategy, Strategy III, was 0.18 (95 %CI 0.06 - 0.53) with an NNT of 56 (95 %CI 34 - 120).

Conclusions: Use of IMP was the most cost-effective strategy, supporting its routine clinical use.

No MeSH data available.


Related in: MedlinePlus