Treatment Management of Bevacizumab and Irinotecan in Patients with Recurrent High-Grade Glioma: A Cost-Effectiveness Analysis

To date, the use of structural MR imaging (including contrast-enhanced and T2-weighted or fluid-attenuated inversion recovery–weighted images) is the standard method to diagnose tumor progression and to assess antiangiogenic treatment effects. However, several studies have suggested that O-(2- 18 F-fluoroethyl)-L-tyrosine ( 18 F-FET) PET adds valuable clinical information to the information derived from structural MR imaging alone. We evaluated the effectiveness and cost-effectiveness of the addition of 18 F-FET PET to structural MR imaging for the management of treatment with bevacizumab and irinotecan (BEV/IR) in patients with recurrent high-grade glioma compared with MR imaging alone from the perspective of the German Statutory Health Insurance. Methods: To evaluate the incremental cost-effectiveness of the additional use of 18 F-FET PET, a decision tree model was used. Effectiveness of 18 F-FET PET was defined as correct identification of both tumor progression before BEV/IR treatment initiation and BEV/IR treatment response and was evaluated for the combination of 18F-FET PET and MR imaging compared with MR imaging alone. Costs were estimated for a baseline scenario and for a more expensive scenario. The robustness of the results was tested using deterministic and probabilistic sensitivity analyses. Results: The use of 18F-FET PET resulted in a number needed to diagnose of 2.4, that is, 3 additional patients have to be diagnosed to avoid 1 wrong diagnosis. The incremental costeffectiveness ratio of 18F-FET PET/MR imaging compared with MR imaging alone was V5,725 (V1 � $1.30) for the baseline scenario and V8,145 for the more expensive scenario per additional correct diagnosis. The probabilistic sensitivity analysis confirmed the robustness of the results. Conclusion: The model suggests that the additional use of 18 F-FET PET in the management of patients with recurrent high-grade glioma treated with BEV/IR may be cost-effective. Integration of 18 F-FET PET has the potential to avoid overtreatment and corresponding costs, as well as unnecessary side effects to the patient.