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Cost–Effectiveness of Surveillance for Distant Recurrence in Extremity Soft Tissue Sarcoma

Trevor J. Royce MD, MS, MPH, Rinaa S. Punglia MD, MPH, Aileen B. Chen MD, MPP, Sagar A. Patel MD, Katherine A. Thornton MD, Chandrajit P. Raut MD, MSc, Elizabeth H. Baldini MD, MPH
Bone and Soft Tissue Sarcomas
Volume 24, Issue 11 / October , 2017

Abstract

Background

Optimal distant recurrence (DR) surveillance strategies for extremity soft tissue sarcoma (STS) are unknown. We performed a cost–effectiveness analysis of different imaging modalities performed at guideline-specified intervals.

Methods

We developed a Markov model simulating lifetime outcomes for 54-year-old patients after definitive treatment for American Joint Committee on Cancer stage II-III extremity STS using four surveillance strategies: watchful waiting (WW), chest X-ray (CXR), chest computed tomography (CCT), and positron emission tomography–computed tomography (PET/CT). Probabilities, utilities, and costs were extracted from the literature and Medicare claims to determine incremental cost–effectiveness ratios (ICER).

Results

CCT was the most effective and most costly strategy with CXR the most cost–effective strategy at a societal willing-to-pay (WTP) of $100,000/quality-adjusted life year (QALY). The ICER was $12,113/QALY for CXR versus $104,366/QALY for CCT while PET/CT was never cost–effective. Sensitivity analyses demonstrated CCT becomes the preferred imaging modality as the lifetime risk of DR increases beyond 33% or as the WTP increases beyond $120,000/QALY.

Conclusions

Optimal DR surveillance imaging for stage II-III extremity STS should be individualized based on patients’ risks for DR. These results suggest CXR, or CCT performed at more protracted intervals, may be preferred for lower-risk patients (i.e., DR risk <33%), whereas CCT may be preferred for higher-risk patients (i.e., DR risk >33%). Further study of optimal strategies is needed. In the interim, these findings may help to refine guidelines to reduce resource overutilization during routine surveillance of lower-risk sarcoma patients.

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