Simianu Vlad V, Varghese Thomas K, Flanagan Meghan R, Flum David R, Shankaran Veena, Oelschlager Brant K, Mulligan Michael S, Wood Douglas E, Pellegrini Carlos A, Farjah Farhood
1 Division of General Surgery, Department of Surgery, 2 Surgical Outcomes Research Center (SORCE), 3 Division of Cardiothoracic Surgery, Department of Surgery, 4 Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA.
J Gastrointest Oncol. 2016 Jun;7(3):395-402. doi: 10.21037/jgo.2015.10.03.
The role of positron emission tomography (PET) in the initial staging of esophageal cancer is to detect occult metastases, but its ability to do so has not been evaluated at the population-level. In 2001, Medicare approved reimbursement of PET for esophageal cancer staging. We hypothesized rapid adoption of PET after 2001 and a coincident increase in the prevalence of stage IV disease.
A retrospective cohort study [1997-2009] was conducted of 12,870 Medicare beneficiaries with esophageal cancer using the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database.
PET use increased from <3% before 2001 to 44% in 2009 (post-PET era) (P trend <0.001). Over the same period, the prevalence of stage IV disease also increased (20% in 1997 and 28% in 2009, P trend <0.001). After adjusting for changing patient characteristics over time, the rate of increase in stage IV disease in the post-PET era [relative risk (RR) =1.06; 95% confidence interval (CI), 1.00-1.13] was no different than the rate of increase in the pre-PET era (RR =1.02; 95% CI, 1.02-1.04). Over the entire study period, the prevalence of unrecorded stage decreased by more than half (43% to 18%, adjusted P trend <0.001) with coincident increases in stage 0-III (37% to 53%, adjusted P trend <0.001) as well as stage IV disease.
The increasing frequency of PET use and stage IV disease over time is more likely explained by improved documentation rather than PET's ability to detect occult metastases. The absence of compelling population-level impact compliments previous studies, revealing an opportunity to increase value through selective use of PET.
正电子发射断层扫描（PET）在食管癌初始分期中的作用是检测隐匿性转移，但尚未在人群水平上评估其检测能力。2001年，医疗保险批准报销用于食管癌分期的PET检查费用。我们推测2001年后PET会迅速得到应用，同时IV期疾病的患病率会相应增加。
利用监测、流行病学和最终结果（SEER）-医疗保险数据库，对12870名患有食管癌的医疗保险受益人进行了一项回顾性队列研究[1997 - 2009年]。
PET的使用从2001年前的<3%增加到2009年（PET后时代）的44%（P趋势<0.001）。在同一时期，IV期疾病的患病率也有所增加（1997年为20%，2009年为28%，P趋势<0.001）。在调整了随时间变化的患者特征后，PET后时代IV期疾病的增加率[相对风险（RR）=1.06；95%置信区间（CI），1.00 - 1.13]与PET前时代的增加率（RR =1.02；95%CI，1.02 - 1.04）没有差异。在整个研究期间，未记录分期的患病率下降了一半以上（从43%降至18%，调整后的P趋势<0.001），同时0 - III期（从37%增至53%，调整后的P趋势<0.001）以及IV期疾病的患病率相应增加。
随着时间的推移，PET使用频率和IV期疾病患病率的增加更可能是由于记录的改善，而不是PET检测隐匿性转移的能力。缺乏令人信服的人群水平影响与先前的研究一致，揭示了通过选择性使用PET来提高价值的机会。
