Li Kevin, Cannon John G D, Jiang Sam Y, Sambare Tanmaya D, Owens Douglas K, Bendavid Eran, Poultsides George A
Stanford University School of Medicine, Li Ka Shing Center, Stanford, California.
VA Palo Alto Health Care System, Palo Alto, California.
J Surg Oncol. 2018 May;117(6):1288-1296. doi: 10.1002/jso.24942. Epub 2017 Dec 4.
Accurate preoperative staging helps avert morbidity, mortality, and cost associated with non-therapeutic laparotomy in gastric cancer (GC) patients. Diagnostic staging laparoscopy (DSL) can detect metastases with high sensitivity, but its cost-effectiveness has not been previously studied. We developed a decision analysis model to assess the cost-effectiveness of preoperative DSL in GC workup.
Analysis was based on a hypothetical cohort of GC patients in the U.S. for whom initial imaging shows no metastases. The cost-effectiveness of DSL was measured as cost per quality-adjusted life-year (QALY) gained. Drivers of cost-effectiveness were assessed in sensitivity analysis.
Preoperative DSL required an investment of $107 012 per QALY. In sensitivity analysis, DSL became cost-effective at a threshold of $100 000/QALY when the probability of occult metastases exceeded 31.5% or when test sensitivity for metastases exceeded 86.3%. The likelihood of cost-effectiveness increased from 46% to 93% when both parameters were set at maximum reported values.
The cost-effectiveness of DSL for GC patients is highly dependent on patient and test characteristics, and is more likely when DSL is used selectively where procedure yield is high, such as for locally advanced disease or in detecting peritoneal and superficial versus deep liver lesions.
准确的术前分期有助于避免与胃癌（GC）患者非治疗性剖腹手术相关的发病率、死亡率和成本。诊断性分期腹腔镜检查（DSL）能够高灵敏度地检测转移灶，但其成本效益此前尚未得到研究。我们建立了一个决策分析模型，以评估术前DSL在GC检查中的成本效益。
分析基于美国一组假设的GC患者队列，其初始影像学检查未显示转移。DSL的成本效益以每获得一个质量调整生命年（QALY）的成本来衡量。在敏感性分析中评估成本效益的驱动因素。
术前DSL每获得一个QALY需要投入107,012美元。在敏感性分析中，当隐匿性转移的概率超过31.5%或转移灶检测灵敏度超过86.3%时，DSL在每QALY 100,000美元的阈值下变得具有成本效益。当两个参数都设定为报告的最大值时，成本效益的可能性从46%增加到93%。
DSL对GC患者的成本效益高度依赖于患者和检查特征，并且在选择性使用DSL且手术收益较高的情况下更有可能具有成本效益，例如用于局部晚期疾病或检测腹膜及肝脏浅表与深部病变时。
