Abstract Rationale National guidelines suggest PET/CT use for nodules suspicious for lung cancer, yet their defined role has not been elucidated. Variability in diagnostic strategies impact time to diagnosis, number of biopsies and healthcare costs. We hypothesize that the use of PET/CT to direct biopsy strategy in the diagnostic work up of lung cancer reduces the number of biopsies and costs. Methods We retrospectively analyzed patients referred to the Miami VA Pulmonary Service for chest imaging concerning lung cancer (February 2013–October 2018). PET/CT scans performed within two months of initial CT were evaluated for impact on number or procedures, radiation exposure and costs. Four theoretical strategies were assessed: (1) biopsy nodule first, then subsequent biopsies after PET/CT; (2) biopsy nodule and mediastinal nodes, then subsequent biopsies after PET/CT; (3) PET/CT first, then biopsy of the highest-stage lesion; (4) PET/CT then stage-directed biopsy directed by an interventional pulmonary center. Results Of 481 patients, 377 underwent PET/CT, and 224 (59. 4%) were diagnosed with lung cancer. Strategy 1 requires 116 additional biopsies, misses disease in 23 (10. 3%), has the lowest radiation exposure and 40. 2% of patients receive diagnosis and stage with one biopsy. Strategy 2 required 55 additional biopsies, misses disease in 7 (3. 1%), also requires the lowest radiation exposure and 72. 3% of patients receive diagnosis and stage with one biopsy. Strategy 3 requires 7 additional biopsies, misses disease in 23 (10. 3%), exposes patients to 10. 1mSV extra radiation per person and 83. 5% of patients receive diagnosis and stage with one biopsy. Strategy 4 requires 7 additional biopsies, misses disease in 7 (3. 1%), exposes patients to 10. 1mSV extra radiation per person and 93. 8% of patients receive diagnosis and stage with one biopsy. Cost analysis is complicated by the wide variability in PET/CT (1, 500-12, 900), percutaneous biopsy (1, 000-9, 000+) and bronchoscopy costs (2, 500-15, 000+). However, strategies using a PET/CT-first approach are cost-equivalent to biopsy-first approaches when the PET/CT scans costs 71. 2% of a biopsy. PET/CTs that cost less are more cost effective. Conclusions This real-world analysis demonstrates that variations in PET/CT utilization affects procedure numbers, missed disease, radiation exposure and costs. These data suggest that using PET/CT first at an interventional pulmonary center minimizes the number of procedures, does increase radiation exposure (∼10. 1 mSv), but may be cost-effective depending on institutional PET/CT versus biopsy costs. This abstract is funded by: none
Gonzalez et al. (Fri,) studied this question.