Cost-effect analysis of the PET-CT system. Analysis in the clinical ...

Cost-effect analysis of the PET-CT system. 

Analysis in the clinical aspect, using Incremental Cost- 

Effectiveness Ratio 

(ICER) 

HEALTH TECHNOLOGY ASSESSMENT (HTA) REPORT 

commissioned by 

Agency for Health Technology Assessment in Poland 

performed by 

Institute of Public Health and Social Insurance 

Business College 

National-Louis University 

Warsaw – Nowy Sącz 2006

PRINCIPAL 

HEALTH TECHNOLOGY ASSESSMENT AGENCY 

Al. Lotników No. 22, 02-668 Warsaw 

tel. +48 22 5667200 

fax +48 22 5667202 

www.aotm.gov.pl 

CONTRACTOR 

INSTITUTE OF PUBLIC HEALTH AND SOCIAL INSURANCE 

BUSINESS COLLEGE 

NATIONAL-LOUIS UNIVERSITY 

Zielona St. No. 27, 33-300 Nowy Sącz 

tel. +48 18 4499120 

fax +48 18 4499121 

e-mail. wsb-nlu@wsb-nlu.edu.pl 

www.wsb-nlu.edu.pl 

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THIS REPORT WAS ASSISSTED BY SPECIALISTS FROM 

CENTRE OF ONCOLOGY - MARIA SKŁODOWSKA –CURIE MEMORIAL INSTITUTE 

Prof. Marek Nowacki MD, PhD 

Prof. Witold Bartnik MD, PhD 

Associate Prof. Mariusz Bidziński MD, PhD 

Associate Prof. Andrzej Kawecki MD, PhD 

Associate Prof. Włodzimierz Ruka MD, PhD 

Associate Prof. Jan Walewski MD, PhD 

Wiesław Lasota MD, PhD 

Janusz Meder MD, PhD 

Andrzej Pietraszek MD, PhD 

Piotr Siedlecki MD, PhD 

Piotr Rutkowski MD, PhD 

INSTITUTE OF PULMONARY DISEASES AND TUBERCULOSIS IN WARSAW 

Prof. Kazimierz Roszkowski-ŚliŜ MD, PhD 

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Cost-effect analysis of PET-CT system. 

Analysis in the clinical aspect, using ICER ratio 

TABLE OF CONTENTS 

1. SUMMARY............................................................................................................................................... 6 

2. HEAD AND NECK MALIGNANT NEOPLASMS – COST-EFFECTIVENESS ANALYSIS –PET-CT vs 

CT DIAGNOSTICS ................................................................................................................................................ 7 

2.1. METASTASES DETECTION ................................................................................................................ 7 

2.1.1. Model description............................................................................................................................ 7 

2.1.2. Model’s transient states................................................................................................................... 8 

2.1.3. Costs calculation ............................................................................................................................. 9 

2.1.4. Model parameters.......................................................................................................................... 12 

2.1.5. Results........................................................................................................................................... 14 

2.1.6. Sensitivity analysis........................................................................................................................ 15 

2.2. Recurrences diagnostics............................................................................................................. 18 

2.2.1. Model description.......................................................................................................................... 18 

2.2.2. Model transient states.................................................................................................................... 18 

2.2.3 Costs calculation ........................................................................................................................... 19 

2.2.4 Model parameters.......................................................................................................................... 23 

2.2.5. Results........................................................................................................................................... 24 


2.3. PRIMARY TUMOR DETECTION IN CASE OF CERVICAL LYMPH NODES METASTASES 

FROM THE UNKNOWN PRIMARY ORIGIN SQUAMOUS CELL CARCINOMA ................................... 29 

2.3.1. Model description.......................................................................................................................... 29 

2.3.2. Model’s transient states................................................................................................................. 29 

2.3.3. Costs calculation ........................................................................................................................... 30 

2.3.4. Model parameters.......................................................................................................................... 34 

2.3.5. Results........................................................................................................................................... 36 


2.4. LITERATURE....................................................................................................................................... 40 

3. NON-SMALL CELL LUNG CANCER – COST-EFFECTIVENESS ANALYSIS – PET-CT vs CT 

DIAGNOSTICS .................................................................................................................................................... 41 

3.1. Model description......................................................................................................................... 41 

3.2. Model’s transient states............................................................................................................... 42 

3.3. Costs calculation .......................................................................................................................... 45 

3.4. Model parameters........................................................................................................................ 48 

3.5. Results............................................................................................................................................... 52 

3.6. Sensitivity analysis.......................................................................................................................... 54 

3.7. LITERATURE....................................................................................................................................... 58 

4. GASTROINTESTINAL STROMAL TUMORS (GIST) – COST-EFFECTIVENESS ANALYSIS –PET-CT 

vs CT DIAGNOSTICS ......................................................................................................................................... 60 





4.5. Results............................................................................................................................................... 65 


4.7. LITERATURE....................................................................................................................................... 70 

5. UNKNOWN PRIMARY ORIGIN DETECTION IN CASE OF CERVICAL LYMPH NODES 

INVOLVEMENT BY THE SQUAMOUS CELL CANCER – COST-EFFECTIVENESS ANALYSIS – PET-CT VS 

CT ................................................................................................................................................................ 71 





5.5. Results............................................................................................................................................... 78 


5.7. LITERATURE....................................................................................................................................... 83 

6. OVARIAN CANCER – COST-comparison ANALYSIS – PET-CT vs CT....................................... 84 

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6.2. Results............................................................................................................................................... 86 

7. OESOPHAGEAL CANCER – COST-comparison ANALYSIS – PET-CT vs CT VE EUS-FNA..... 87 


7.2. Results............................................................................................................................................... 89 

8. LYMPHOMAS – COST-COMPARISON ANALYSIS – PET-CT vs CT.............................................. 91 


8.2. Results............................................................................................................................................... 93 

9. THYROID CANCER – COST-COMPARISON ANALYSIS – PET-CT vs WHOLE-BODY 

SCINTIGRAPHY................................................................................................................................................... 94 


9.2. Results............................................................................................................................................... 96 

10. PANCREATIC CANCER – COST-COMPARISON ANALYSIS – PET-CT vs CT ............................ 97 


10.2. Results............................................................................................................................................... 99 

11. COLON CANCER - no analysis - PET-CT vs CT .......................................................................... 100 

12. DISCUSSION ....................................................................................................................................... 101 

13. LIST OF TABLES ................................................................................................................................... 103 

14. LIST OF FIGURES................................................................................................................................. 107 

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1. SUMMARY 

The aim of this report is a comparative cost- 

effectiveness analysis of the PET-CT technology (positron 

emission tomography - PET fused with computed 

tomography - CT) and the diagnostic technologies 

financed from public sources in oncological diagnostics 

in Poland. The efficacy of the compared diagnostic 

methods was assessed in the clinical part of the report, 

entitled “Comparative cost – effect analysis of the 

positron emission tomography PET-CT with diagnostic 

technologies financed in Poland from the public assets 

in the oncologic diagnostics - epidemiological and 

clinical part”. That part includes particular description of 

populations, intervention, compartors, outcomes, used 

studies design and results (accuracy of compared 

diagnostic tests). 

The study was prepared for the Agency for Health 

Technology Assessment in Poland. 

Only indications with statistically significant differences 

of compared methods diagnostic efficacy were 

included into the cost-effectiveness analysis. 

Clinical effects were estimated on a basis of available 

data from studies and experts’ estimations. 

Costs, from the Polish public payer’s perspective were 

estimated on a basis of the available data concerning 

procedures used in particular indications, in a time 

horizon equal to patients’ life expectancy. 

Cost-effectiveness analysis, using ICER ratio, was 

performed in the following indications: 

• head and neck malignant neoplasms 

metastases diagnostics, using PET-CT system is 

more expensive, but more effective than 

computed tomography diagnostics – 

incremental cost-effectiveness ratio (ICER) 

amounts 8,100.09 PLN/LYG; 

• head and neck malignant neoplasms 

recurrence diagnostics, using PET-CT system is 

more expensive, but more effective than 

computed tomography diagnostics – 





• unknown primary origin of head and neck 

malignant neoplasms diagnostics, using PET-CT 

system is more expensive, but more effective 

than computed tomography diagnostics – 



• non-small cell lung cancer staging, using PET- 

CT system is more expensive, but more 

effective than computed tomography 

diagnostics – incremental cost-effectiveness 

ratio (ICER) amounts 152,862.22 PLN/LYG; 

• assessment of GIST response to imatinib 

therapy, using PET-CT system is more expensive, 

but more effective than computed 

tomography diagnostics – incremental cost- 

effectiveness ratio (ICER) amounts 159,626.51 

PLN/LYG; 

• primary tumor of unknown primary origin 

malignant neoplasms diagnostics, using PET-CT 

system is more expensive, but more effective 

than computed tomography diagnostics – 



In all mentioned above indications, the diagnostic 

efficacy differences of compared methods lead to 

differences of clinical efficacy and treatment costs. PET- 

CT was more effective and simultaneously more 

expensive diagnostic method than other compared 

techniques. 

In case of ovarian cancer, oesophageal cancer, 

lymphomas and pancreatic cancer, the cost 

comparison analysis was performed, due to the lack of 

possibility to perform the analysis using the ICER ratio. 

PET-CT method, revealed in all cases to be more 

expensive than other compared diagnostic procedures. 

In colon cancer diagnostics available data was 

insufficient for any analysis. 

6



2. HEAD AND NECK MALIGNANT NEOPLASMS – COST- 

EFFECTIVENESS ANALYSIS –PET-CT VS CT DIAGNOSTICS 

In the cost-effectiveness analysis, comparing PET-CT and CT in diagnostic of head and neck 

malignant neoplasms, three decision models were used, concerning the following indications: 

• distant metastases diagnostics in the primary head and neck malignant neoplasms 

staging – patients from the high-risk group of the generalized disease; 

• follow-up diagnostics after the head and neck malignant neoplasms treatment, 

aiming to detect the possible disease recurrences; 

• diagnostics performed in case of lymph nodes involvement by the squamous cell 

carcinoma: detection of the unknown primary origin of the neoplasm. 

The efficacy of the compared diagnostic methods was assessed in the clinical part of the 

report, entitled “Comparative cost – effect analysis of the positron emission tomography PET- 

CT with diagnostic technologies financed in Poland from the public assets in the oncologic 

diagnostics - epidemiological and clinical part”. Clinical effects were estimated on a basis of 

available data from studies or experts’ estimations. Costs, from the Polish public payer’s 

perspective were estimated on a basis of the available data concerning procedures used in 

particular indications, in a time horizon equal to patients’ life expectancy. 

2.1. METASTASES DETECTION 

2.1.1. Model description 

Model utilized in the cost-effectiveness analysis concerns a group of patients with head and 

neck malignant neoplasm, with a high risk, estimated on a basis of the preliminary clinical 

assessment, of distant metastases. PET-CT and CT diagnostics effects and costs were 

compared. Decision model, using a TreeAge ® 2004 (version 7) software, was used in the 

analysis. Time horizon was estimated until patient’s death, cost data were estimated from the 

public payer’s perspective, on a basis of available information. The efficacy of the compared 

diagnostic methods was assessed in the clinical part of the report, entitled “Comparative cost 

– effect analysis of the positron emission tomography PET-CT with diagnostic technologies 

financed in Poland from the public assets in the oncologic diagnostics - epidemiological and 

clinical part”. Data concerning the treatment effects and consequences of the improper 

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treatment, resulting from the misdiagnosing, were obtained from the literature or from experts' 

estimation, in case of unavailable data. 

Information concerning effectiveness of the diagnostic test to obtain correct estimation of 

the patient as well as data concerning diagnostic errors were incorporated into the model. 

Improper diagnostics may cause health or financial losses. 

2.1.2. Model’s transient states 

Decision model contains the following transient states (equal for both variants of the 

diagnostic procedure): 

• “Head and neck neoplasms” is a baseline state, characterizing patients population 

at the beginning of treatment. After the diagnostic procedure, there is a possibility to 

pass into the following states: 

o Diagnosis: metastases (in case when the procedure revealed metastases); 

o Diagnosis: no metastases (if there were no signs of metastases). 

• “Diagnosis: metastases” – contains patients with diagnosed metastases of the head 

and neck malignant neoplasms. If the metastases are diagnosed, the two final states 

may occur: 

o Patients with metastases (in case of the correct diagnosis of metastases); 

o Patient without metastases (if the metastases were incorrectly diagnosed). 

• “Diagnosis: no metastases” – this state contains patients without diagnosed 

metastases of the head and neck malignant neoplasms. If no metastases were 

diagnosed, there is a possibility to pass into the following final states: 

o Patient with metastases (if the diagnosis of lack of metastases was incorrect); 

o Patient without metastases (if the lack of metastases was correctly 

diagnosed). 

The following figure shows the illustration of the decision tree, describing the course of 

metastases detection, using PET-CT and computed tomography. Main model parameters are 

shown in the table below. 

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Figure 1. 

Decision tree showing the model used in the calculations of PET-CT vs CT comparison, used in the diagnostics of the 

head and neck malignant neoplasms metastases (legend – table 6) 

As presented in the figure 1, it is assumed that all patients with positive result of diagnostic 

tests had palliative treatment, patients with true negative result had surgical treatment, and 

patients with false negative results had both surgical and palliative treatments. 

2.1.3. Costs calculation 

In the studies concerning head and neck malignant neoplasms, the PET-CT method was 

compared to the computed tomography with contrast media (CT). Computed tomography 

(CT) of the head is an out-patient, co-financed (ASDW) diagnostic service, that amounts 28 

points – 23 points are refunded by the National Health Fund and the 5 remaining points are 

covered by a physician referring to the procedure (“Catalogue of the co-financed out- 

patient diagnostic procedures ranges (ASDW)”. The attachment No 1b, to the AOS 

informational materials). Referrer covers the cost of performed procedure, according to the 

negotiated price of the point. The National Health Fund covers the cost of the co-financed 

diagnostic procedure, accordingly to the prices of the point, negotiated by: health care 

provider performing the procedure and by the referrer. 

It was assumed that referring center is the oncologic dispensary. The average price of the 

settlement point in the oncologic dispensary, calculated on the basis of the point price in all 

such institutions in Poland, bounded with the NHF contract (data in the annex), amounts 7.54 

PLN. 

Similarly, the average point price in the computed tomography laboratory, calculated on 

the basis of the point price in all computed tomography laboratories having the contract 

with the National Health Fund in Poland, amounts 8.05 PLN. 

The following table shows the characteristics of the CT service from the ASDW catalogue, 

together with its cost calculation. 

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Table 1. 

Service characteristics and the head computed tomography cost calculation, on a basis of the ASDW catalogue 

Type of the 

diagnostic test 

Computed 

tomography 

(CT) 

with contrast media 

Name and code of 

the procedure 

CT: CT of the head 


5.03.00.0000025 

NHF refund 

Points value 

Referrer’s 

surcharge 

Average price of 1 point 

[PLN] 

CT laboratory Oncologic 

dispensary 

Test 

cost 

(PLN) 

23 5 8,05 7,54 222,85 

PET-CT is an individually contracted service, amounting 420 points. The average price of 

the settlement point in positron emission tomography in the Center of Oncology in Bydgoszcz, 

the sole provider performing PET examination, amounts 10.75 PLN. 

The following table shows the characteristics of the PET-CT service from the individually 

contracted services catalogue, together with the unitary cost calculation. 

Table 2. 

Service characteristics and PET-CT diagnostics calculation, on the basis of the individually contracted services 

catalogue 



PET-CT 



the service 

Positron emission 

tomography (PET) 

5.10.00.0000042 



[PLN] 

Test cost [PLN] 

420 10,75 4 515,00 

The average CT examination cost in the diagnostics of the head and neck malignant 

neoplasm amounts 222.85 PLN, and the PET-CT examination cost – from the public payer’s 

perspective – amounts 4,515.00 PLN. 

The following table shows selected items, from the NHF’s catalogue of services, used to 

calculate the costs of 6 cycles of chemotherapy or 6 months of palliative chemotherapy. 

Table 3. 

Costs of the selected therapies, from the NHF services catalogue, used in head and neck malignant neoplasms 

treatment 


therapy 

PF 

Active substances Posology 

CIS-PLATINUM // 

FLUOROURACILUM 

100 mg/m 2 iv / day 1 // 800–1000 mg/m 2 iv 

days 1–4 (CONTINUOUS INFUSION 96 H 

WITH/WITHOUT RADIOTHERAPY) 

Code=No of 

points x point 

price (10 PLN) 

[PLN] 

7 148,40 

MTX METHOTREXATUM 40 mg/m 2 iv day 1, every 7 days 3 098,40 

10

PFH&N 

PFELVH&N 

PF1 






FLUOROURACILUM // 

VINBLASTINUM // ETOPOSIDUM 

// CALCII FOLINAS 



P CIS-PLATINUM 

20 mg/m 2 /day iv (continuous infusion) days 

1–5 // 

500 mg/m 2 /day iv ( continuous infusion)days 

1–7 and days 15, 22, 29 every 28 days 

30 mg/m 2 iv days 1–3 // 500 mg/m 2 iv days 1– 

3 // 3 mg/m 2 iv day 1 // 100 mg/m 2 iv days 2 

and 3 // 25 mg/m 2 iv days 1–3 every 21 days 

25 mg/m 2 iv days 1–4 // 1000 mg/m 2 iv days 

1–4 every 28 days 

40 mg/m 2 iv day 1, every 7 days IN 

COMBINATION WITH RADIOTHERAPY 

13 963,20 

6 376,80 

7 148,40 

3 636,00 

Table 4 contains information about selected radiotherapeutic procedures, from the NHF’s 

catalogue of services, used in head and neck malignant neoplasms treatment, as well as its 

cost. 

Table 4. 

Costs of the selected radiotherapeutic procedures used in head and neck malignant neoplasms treatment, on a basis 

of the NHF services catalogue 

Type of service 

Code of the 

procedure 

Cost of the procedure =No of points 

x point price (10 PLN) [PLN] 

palliative teleradiotherapy 5.07.01.0000021 1 800 

radical teleradiotherapy with twodimensional 

(2D) planning 

radical teleradiotherapy with threedimensional 


5.07.01.0000022 5 000 

5.07.01.0000023 8 000 

standard brachytherapy 5.07.01.0000025 4 000 

3D brachytherapy with real time planning 5.07.01.0000026 5 200 

The table below contains selected procedures, from the NHF’s catalogue of services, 

including operative treatment of head and neck malignant neoplasms metastases, as well as 

its cost. 

Table 5. 

Surgical procedures used in head and neck malignant neoplasms metastases treatment 

Name of the procedure Code of the procedure 

Cost of the procedure 

=No of points x point price 

(10 PLN) [PLN] 

excision of the maxillary neoplasm – partial 5.06.00.0000481 7 000 

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and total resection of the maxilla 

Total or partial laryngectomy with the lymph 

nodes operation / with or without CO2 laser / 

with tracheostomy 

Radical or modified excision of the cervical 

lymphatic system 

Excision of the neoplasm of the oral cavity 

bottom, tongue, soft palate, cheek and the 

medial pharynx with cervical lymph nodes 

excision 




excision, mandibulotomy and/or without partial 

mandible resection 

Salivary gland neoplasm excision with cervical 

lymphangiectomy 

Mandible excision (hemiresection) with 

possible cervical lymphangiectomy 

Parotid gland neoplasm excision with the facial 

nerve reconstruction or with facial nerve 

preservation 

Eyelid neoplasm, exceeding over the orbit 

outline – surgical treatment 



5.06.00.0000682 5 200 

5.06.00.0000689 4 800 

5.06.00.0000479 7 000 

5.06.00.0000480 8 000 

5.06.00.0000482 5 000 

5.06.00.0000483 6 000 

5.06.00.0000484 4 500 

5.06.00.0000134 2 000 

Nose neoplasm excision 5.06.00.0000160 2 600 

Skin/soft tissue neoplasm excision with 

synthetic implants reconstruction or with 

pedunculated lobes 

5.06.00.0000161 3 800 

Orbit neoplasm – surgical treatment 5.06.00.0000214 5 000 



medial pharynx 

2.1.4. Model parameters 

Main model parameters are shown in the table below. 

5.06.00.0000478 5 000 

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Table 6. 

List of model parameters with values used in the sensitivity analysis of PET-CT vs CT comparison in the head and 

neck malignant neoplasms metastases diagnostics 

Parameter PET-CT CT 

Cost of the diagnostic procedure 

[PLN] 

Cost of surgical treatment (and/or 

radiotherapy) (cChir) [PLN] 

Cost of palliative therapy (cPaliat) 

[PLN] 

Survival after surgical treatment 

(eP_Chir) [years] 

Survival after palliative chemotherapy 

(eP_Paliat) [years] 


– wrong diagnosis (eP_Paliat2) [years] 

Probability of diagnostic procedure 

positive result (TP+FP) 

Probability of the correct metastases 

detection (pTP) 

4 515,00 (1 313,00*) 222,85 (174,50; 274,00) 

5 000,00 (2 000,00; 16 000,00) 

7 148,40 (3 098,40; 13 963,20) 

5,0 (4,0; 6,0)** 

1,0 (0,9; 1,1)** 

1,2 (1,1; 1,3)** 

0,3680 (0,3249; 0,4111) 

0,9783 (0,9568; 0,9998) 0,7391 (0,6744; 0,8039) 

Probability of wrong metastases 

detection (pFP) 0,0217 (0,0002; 0,0432) 0,2609 (0,1961; 0,3256) 

Probability of correct lack of 

metastases detection (pTN) 

Probability of wrong lack of 

metastases detection (pFN) 

0,9241 (0,8850; 0,9631) 0,7468 (0,6827; 0,8109) 

0,0759 (0,0369; 0,1150) 0,2532 (0,1891; 0,3173) 

*“threshold” PET-CT cost at 7,700 procedures per year (estimated in the “Assessment of the PET-CT diagnostics in the 

Center of Oncology in Bydgoszcz” report) 

** on a basis of the literature and experts’ estimations 

• PET-CT cost amounts 4,515.00 PLN (alternative PET-CT cost, amounting 1,313.00 PLN 

was also assumed – cost estimated in the “Assessment of the PET-CT diagnostics in the 

Center of Oncology in Bydgoszcz” report). 

• The average CT cost amounts 222.85; minimal cost of this procedure amounted 174.50 

PLN, maximal – 274.00 PLN. 

• The average cost of the head and neck malignant neoplasms treatment was 

assumed as equal to the cost of procedure No 5.06.00.0000482 from the catalogue of 

hospital services (range of costs between minimal and maximal cost of surgical 

procedures used in head and neck malignant neoplasms metastases treatment with 

consecutive radiotheraphy – see table 4 and 5). 

• The average cost of the head and neck malignant neoplasms palliative treatment 

was assumed the cost of 6 cycles of PF chemotherapy, from the catalogue of 

oncologic services (range of costs between minimal and maximal cost of palliative 

chemotherapy used in head and neck malignant neoplasms metastases treatment – 

see – table 3). 

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• Life expectancy after surgical treatment, survival after palliative chemotherapy and 

survival after the palliative chemotherapy in case of wrong metastases diagnosis and 

its minimal and maximal values were assumed on a basis of literature and estimation 

of experts from the Maria Skłodowska - Curie Memorial Institute Center of Oncology in 

Warsaw. 

• Values of the parameters concerning diagnostic tests accuracy were taken from the 

report entitled: ”Comparative cost – effect analysis of the positron emission 

tomography PET-CT with diagnostic technologies financed in Poland from the public 

assets in the oncologic diagnostics - epidemiological and clinical part”, based on 

information from the following publication: 

o Branstetter IV BF, Blodgett TM, Zimmer LA, Snyderman CH, Johnson JT, Raman 

2.1.5. Results 

S, Meltzer CC. Head and neck malignancy: Is PET-CT more accurate than PET 

or CT alone?. Radiology 2005; Vol. 235 (2): pp 580–586. 

The following table contains results of the comparative cost-effectiveness analysis of the 

PET-CT vs head computed tomography in the head and neck malignant neoplasms 

metastases diagnostics, where average survival of patients (in years) is considered as effect. 

Cohort simulation method was used in calculations. 

Table 7. 

List of cost-effectiveness analysis results of the PET-CT vs CT in the head and neck malignant neoplasm metastases 

diagnostics 

Procedure 

Cost per one 

patient [PLN] 

Cost difference 

[PLN] 

Average 

survival [years] 

PET-CT 10 648,51 3,338 

CT 7 157,37 

3 491,14 

2,907 

Effects 

difference 

(LYG) 

ICER 

[PLN/LYG] 

0,431 8 100,09 

The analysis revealed that head and neck malignant neoplasms diagnostics using PET-CT is 

more expensive than using computed tomography, but simultaneously gives better long-term 

effect, measured with the quantity of life years gained. Total PET-CT cost included costs of the 

diagnostic procedure, metastases surgical treatment and costs of palliative chemotherapy. 

Costs difference between diagnostic procedures amounts 3,491.14 PLN per one patient. 

Using PET-CT in one patient, may result in gaining the effect of 3.338 life years. In a group of 

patients diagnosed with computed tomography, the predicted effect amounts 2.907 life 

14



years. Effects difference between using PET-CT and CT amounts 0.431 LYG (life years gained), 

i.e. approx. 157 days. 

Head and neck malignant neoplasms diagnostics using PET-CT is more expensive and 

simultaneously more effective than using computed tomography. Incremental cost- 

effectiveness ratio (ICER) amounts 8,100.09 PLN/LYG that means, gaining one additional life 

year using PET-CT instead of CT costs 8,100.09 PLN. 

Cost-effectiveness analysis was also performed using Monte Carlo simulation method for 

100,000 patients. Results are shown in table 8. 

Table 8. 

Results of analysis obtained using the Monte Carlo simulation method for 100,000 patients, comparing PET-CT vs CT 

in the head and neck malignant neoplasm metastases diagnostics 

Parameter 

PET-CT CT 

Cost (PLN) Effect [years] Cost (PLN) Effect [years] 

ICER 

[PLN/LYG] 

Mean 10 645,57 3,344 7 160,97 2,909 8 010,57 

Standard deviation 1 693,56 1,969 2 482,48 1,980 

Minimal value 9 515,00 1,000 5 222,85 1,000 

Median 9 515,00 5,000 7 371,25 1,200 


Results obtained using Monte Carlo method do not differ form results obtained in the cohort 

simulation method. PET-CT diagnostics remains more expensive procedure and more 

effective than using computed tomography only. The difference of average effect amounts 

0.435 life year. Effect median, in a group of patients diagnosed using PET-CT amounts 5 years, 

and in the CT group – 1.2 year. Incremental cost-effectiveness ratio (ICER) amounts 8,010.57 

PLN/LYG that means, using PET-CT instead of CT in the head and neck malignant neoplasms 

metastases detection costs 8,010.57 PLN. 

2.1.6. Sensitivity analysis 

One-way sensitivity analysis for the comparison of head and neck metastases detection 

using PET-CT vs computed tomography was performed for different model parameters: 

- 

15



• assumption the PET-CT cost amounting 1,313.00 PLN (“subthreshold” PET-CT cost at 

7,700 procedures per year, estimated in the “Assessment of the PET-CT diagnostics in 

the Center of Oncology in Bydgoszcz” report); 

• minimal and maximal costs of CT; 

• assumption of alternative CT cost amounting 335.55 PLN – one or more parts of the 

body examination; 

• minimal and maximal costs of surgical treatment; 

• minimal and maximal costs of palliative treatment; 

• minimal and maximal life expectancy after surgical treatment; 

• minimal and maximal life expectancy after palliative chemotherapy; 

• minimal and maximal life expectancy after palliative chemotherapy, in case of wrong 

metastases diagnosis; 

• minimal and maximal probabilities of gaining positive result in PET-CT and CT; 

• minimal and maximal probabilities of correct and incorrect metastases detection; 

• minimal and maximal probabilities of correct and incorrect lack of metastases 

detection; 

Sensitivity analysis results for variable model parameters are shown in the table below. 

Table 9. 

Sensitivity analysis of the PET-CT vs CT in the head and neck malignant neoplasm metastases diagnostics 

Parameter 

Cost (PLN) 


Effect 

[years] 

Cost (PLN) 

Effect 

[years] 

ICER [PLN/LYG] 

Baseline state 10 648,51 3,338 7 157,37 2,907 8 100,09 

Alternative PET-CT cost 7 446,51 3,338 7 157,37 2,907 670,86 

Minimal CT cost 10 648,51 3,338 7 109,02 2,907 8 212,27 

Maximal CT cost 10 648,51 3,338 7 208,52 2,907 7 9818,41 

Alternative CT cost 10 648,51 3,338 7 270,07 2,907 7 838,61 

Minimal cost of surgical 

treatment 

Maximal cost of surgical 

treatment 

8 752,51 3,338 5 261,37 2,907 8 100,09 

17 600,51 3,338 14 109,37 2,907 8 100,09 

Minimal cost of palliative 8 963,84 3,338 5 018,87 2,907 9 153,06 

16


Maximal cost of palliative 


Minimal survival after surgical 

treatment 

Maximal survival after surgical 

treatment 

Minimal survival after palliative 

chemotherapy 

Maximal survival after palliative 


Minimal survival after palliative 

chemotherapy – wrong 

diagnosis 

Maximal survival after palliative 

chemotherapy – wrong 

diagnosis 

Minimal probability of gaining a 

positive result in PET-CT 



13 483,26 3,338 10 755,73 2,907 6 328,38 

10 648,51 2,754 7 157,37 2,435 10 959,30 

10 648,51 3,922 7 157,37 3,379 6 433,36 

10 648,51 3,297 7 157,37 2,864 8 062,68 

10 648,51 3,379 7 157,37 2,950 8 137,86 

10 648,51 3,337 7 157,37 2,898 7 952,48 

10 648,51 3,339 7 157,37 2,917 8 272,84 

10 579,46 3,496 7 157,37 2,907 5 810,00 

Maximal probability of gaining a 

positive result in PET-CT 10 717,56 3,179 7 157,37 2,907 13 088,93 

Minimal probability of gaining a 

positive result in CT 

Maximal probability of gaining a 

positive result in CT 

Minimal probability of correct 

metastases detection 

Maximal probability of correct 


Maximal probability of incorrect 



lack of metastases detection 





10 648,51 3,338 7 142,81 3,033 11 494,10 

10 648,51 3,338 7 171,92 2,781 6 241,63 

10 648,51 3,339 7 157,37 2,912 8 167,78 

10 648,51 3,336 7 157,37 2,902 8 047,88 

10 648,51 3,339 7 157,37 2,912 8 167,78 

10 825,16 3,239 7 446,96 2,745 6 841,11 

10 472,32 3,436 6 867,78 3,069 9 817,44 

10 825,16 3,239 7 446,96 2,745 6 841,11 

Generally, in the sensitivity analysis there were not any abrupt changes of costs and effects 

for the described parameters, characterizing compared diagnostic schemes. Head and neck 

malignant neoplasm diagnostics using PET-CT remains more expensive and more effective 

than CT. The minimal ICAR value was observed in case of assumption the alternative cost of 

17



PET-CT procedure on the level of 1,313.00 PLN (decrease of 91.71%). Maximal ICER value was 

observed in case of assumption the maximal probability of obtaining a positive result in PET-CT 

examination (ICER increase of 61.58% from the baseline value). 

2.2. RECURRENCES DIAGNOSTICS 


Model used in the cost-effectiveness analysis concerns a group of patients with head and 

neck malignant neoplasms undergoing follow-up diagnostics after treatment, aiming to 

detect the possible disease recurrence. Effects and costs of PET-CT and CT diagnostics were 

compared. In the analysis, a decision model (TreeAge® 2004 software – version 7) was used. 

Time until death of patient was assumed as a time horizon, cost data were estimated from 

the public payer’s perspective, on a basis of available data. The effectiveness of compared 

diagnostic procedures was assessed in a clinical par of “Comparative cost – effect analysis of 

the positron emission tomography PET-CT with diagnostic technologies financed in Poland 

from the public assets in the oncologic diagnostics - epidemiological and clinical part” 

report. Data concerning treatment effects and consequences of incorrect treatment 

resulting from the incorrect diagnosis was presented on a basis of literature or experts' 

estimation, in case of unavailability of the data. 

Information concerning the ability of the test to correct patient assessment and data 

concerning errors in diagnostics were used in the model. Incorrect diagnostics may result in 

health and financial losses. 

2.2.2. Model transient states 

Decision model includes the following transient states (same for both variants of diagnostic 

procedure): 

• „Head and neck neoplasms” basal state, characterizing patients population at the 

beginning of treatment. After diagnostic procedure patient may pass to the following 

states: 

o Diagnosis: recurrence (if the diagnostic procedure revealed head and neck 

malignant neoplasm recurrence); 

18



o Diagnosis: no recurrence (if there is no recurrence of head and neck 

malignant neoplasm). 

• “Diagnosis: recurrence” – includes patients diagnosed with head and neck malignant 

neoplasms recurrence. After recurrence detection, patients may pass to the following 

final states: 

o Patient with recurrence (in case of correct recurrence detection); 

o Patient without recurrence (in case of incorrect recurrence detection). 

• “Diagnosis: no recurrence” – includes patients diagnosed without head and neck 

malignant neoplasms recurrence detection. if the recurrence is not detected, patient 

may pass to the following final states: 

o Patient with recurrence (in case of incorrect lack of recurrence detection); 

o Patient without recurrence (in case of correct lack of recurrence detection). 

The following figure shows an illustration of the decision model, describing the course of 

head and neck malignant neoplasms recurrences detection in patient diagnosed using PET- 

CT or computed tomography. 

Figure 2. 

Decision tree presenting model used in calculations of PET-CT vs CT comparison, in the head and neck malignant 

neoplasms recurrences detection (legend - table 15) 


tests had palliative chemotherapy treatment, patients with negative result had no treatment. 

19

2.2.3 Costs calculation 








patient diagnostic procedures ranges (ASDW)”. Annex No. 1b to the informational materials 

AOS). Referrer covers the cost of performed procedure, according to the negotiated price of 

the point. The National Health Fund covers the cost of the co-financed diagnostic procedure, 

accordingly to the prices of the point, negotiated by: health care provider performing the 

procedure and by the referrer. 




PLN. 






Table 10. 

Service characteristics and the computed tomography cost calculation, on a basis of the ASDW catalogue 



Computed 

tomography 





CT: Head CT with the 

contrast media 

5.03.00.0000025 

NHF refund 


Referrer’s 

surcharge 


[PLN] 


dispensary 

Test 

cost 

(PLN) 

23 5 8,05 7,54 222,85 

PET-CT is an individually contracted service, amounting 420 points. The average price of the 

settlement point in positron emission tomography in the Center of Oncology in Bydgoszcz, the 

sole provider performing PET examination, amounts 10.75 PLN. 

20





Table 11. 


catalogue 









5.10.00.0000042 



[PLN] 

420 10,75 


4 515,00 






Table 12. 

Costs of the selected therapies, from the NHF services catalogue, used in head and neck malignant neoplasms 

treatment 



PF 




100 mg/m 2 iv day 1 // 800–1000 mg/m 2 iv 

days 1–4 (CONTINUOUS INFUSION 96 H WITH 

OR WITHOUT COMBINATION WITH 

RADIOTHERAPY) 

Cost of the 

procedure =No 

of points x point 


[PLN] 

7 148,40 

MTX METHOTREXATUM 40 mg/m 2 day 1 every 7 days 3 098,40 

PFH&N 

PFELVH&N 

PF1 











1–5 // 500 mg/m 2 /day iv (continuous infusion) 

days 1-7 and days 15, 22, 29 every 28 days 





4 every 28 days 

40 mg/m 2 iv day 1 every 7 days IN 


13 963,20 

6 376,80 

7 148,40 

3 636,00 

21



Table 13. contains selected radiotherapeutic procedures from the NHF’s catalogue of 

services, used in head and neck malignant neoplasms treatment and its cost. 

Table 13. 

Costs of selected radiotherapeutic procedures used in head and neck malignant neoplasms treatment, on a basis of 

NHF's catalogue of services. 



procedure 








5.07.01.0000022 5 000 

5.07.01.0000023 8 000 



The table below contains selected procedures, from the NHF’s catalogue of services as well 

as cost of operative treatment of head and neck malignant neoplasms recurrences. 

Table 14. 

Surgical procedures used in head and neck malignant neoplasms treatment 


excision of the maxillary neoplasm – partial 










excision 













5.06.00.0000481 7 000 

5.06.00.0000682 5 200 

5.06.00.0000689 4 800 

5.06.00.0000479 7 000 

5.06.00.0000480 8 000 

5.06.00.0000482 5 000 

5.06.00.0000483 6 000 

22



preservation 





5.06.00.0000484 4 500 

5.06.00.0000134 2 000 





5.06.00.0000161 3 800 





2.2.4 Model parameters 

Main model parameters are presented in the table below. 

5.06.00.0000478 5 000 

Table 15. 

List of model parameters with values used in the sensitivity analysis of PET-CT vs CT comparison in the head and 

neck malignant neoplasms recurrences diagnostics 



[PLN] 


[PLN] 

Survival in case of no recurrence 

(eP_Brak Nawrotu) [years] 


(eP_Paliat) [years] 

Survival after no treatment (delayed 

palliative chemotherapy) – wrong 

diagnosis (eP_Paliat2) [years] 



Probability of correct recurrence 

detection (pTP) 

Probability of incorrect recurrence 

detection (pFP) 

Probability of correct lack of 

recurrence detection (pTN) 

4 515,00 (1 313,00*) 222,85 (174,50; 274,00) 

7 148,40 (3 098,40; 13 963,20) 

5,0 (4,0; 6,0) 

1,0 (0,9; 1,1) 

0,7 (0,6; 0,8) 

0,3680 (0,3249; 0,4111) 

0,9783 (0,9568; 0,9998) 0,7391 (0,6744; 0,8039) 

0,0217 (0,0002; 0,0432) 0,2609 (0,1961; 0,3256) 

0,9241 (0,8850; 0,9631) 0,7468 (0,6827; 0,8109) 

Probability of wrong lack of 0,0759 (0,0369; 0,1150) 0,2532 (0,1891; 0,3173) 

23

ecurrence detection (pFN) 










• Cos of 6 cycles of PF chemotherapy (form the oncologic procedures catalogue) was 

assumed as an average cost of palliative treatment, in case of head and neck 

malignant neoplasms (the costs range between minimal and maximal cost of 

palliative chemotherapy, used in head and neck malignant tumors treatment – see 

table 12). 

• Life expectancy, after palliative chemotherapy without recurrence and life 

expectancy after the delayed palliative chemotherapy, due to the wrong diagnosis, 

as well as its minimal and maximal valued are presented, on a basis of literature or 

experts’ from the Maria Skłodowska – Curie Memorial Institute in Warsaw. 

• Values of the rest of parameters were taken from the report: “Comparative cost – 

effect analysis of the positron emission tomography PET-CT with diagnostic 

technologies financed in Poland from the public assets in the oncologic diagnostics - 

epidemiological and clinical part”. Information from the following publications were 

used: 





The following table shows results of the comparative cost-effectiveness analysis of PET-CT vs 

computed tomography used in head and neck malignant neoplasms recurrence 

diagnostics, where the average life expectancy expressed in years, was considered as the 

effect. Cohort simulation method was used in calculations. 

24



Table 16. 

Results of the cost-effectiveness analysis of the PET-CT vs CT in the head and neck malignant neoplasm recurrence 

diagnostics 

Procedure 


patient [PLN] 


[PLN] 

Average life 

expectancy 

[years] 



4 292,15 

3,224 

Effects 

difference 

(LYG) 

ICER 

[PLN/LYG] 

0,130 33 016,54 

Cost-effectiveness analysis revealed, that head and neck malignant neoplasms diagnostics 

using PET-CT is more expensive than using computed tomography, but simultaneously gives a 

better long-term effect, measured with life years gained ratio. Total PET-CT and CT cost 

included costs of the diagnostic procedure, surgical treatment and costs of palliative 

chemotherapy. The cost difference between diagnostic procedures amounts 4,292.15 PLN 

per one patient. Using PET-CT in one patient allows to gain 3.354 life years. In a group of 

patients, where computed tomography is performed, the anticipated effect amounts 3.224 

life years. Difference of effects between PET-CT and CT amounts 0.130 LYG (life years gained) 


Head and neck malignant neoplasms recurrence diagnostics, using PET-CT system is more 

expensive, but more effective than computed tomography diagnostics. Incremental cost- 

effectiveness ratio amounts 33,016.54 PLN/LYG, that means, gaining one additional year of 

life using PET-CT diagnostics instead of CT, costs 33,016.54 PLN. 



25



Table 17. 

Results of the Monte Carlo simulation analysis for 100,000 patients, comparing the PET-CT vs CT in the head and neck 

malignant neoplasm recurrence diagnostics 

Parameter 


Cost [PLN] Effect [years] Cost [PLN] Effect [years] 

ICER 

[PLN/LYG] 

Average 7 143,07 3,353 2 850,92 3,225 33 532,42 


Minimal value 4 515,00 0,700 222,85 0,700 

Median 4 515,00 5,000 222,85 5,000 

Maximal value 11 663,40 5,000 7 371,25 5,000 

Results obtained using the Monte Carlo method do not differ from results obtained in the 

cohort simulation method. PET-CT diagnostics method remains more expensive and more 

effective than using computed tomography only. Difference of effects averages amounts 

0.128 of a life year. Median of the effect in a group of patients diagnosed using PET-CT and 

CT amount 5 life years. Incremental cost-effectiveness ratio amounts 33,532.42 PLN/LYG, that 

means, gaining one additional year of life using PET-CT diagnostics in head and neck 

malignant neoplasms recurrence detection, instead of CT, costs 33,532.42 PLN. 


One-way sensitivity analysis of the PET-CT vs CT diagnostics in head and neck malignant 

neoplasms recurrence detection was performed for the different model parameters; 

• assumption the alternative PET-CT cost on the level of 1,313.00 PLN (“threshold” PET-CT 

cost at 7,700 procedures per year, estimated in the “Assessment of the PET-CT 

diagnostics in the Center of Oncology in Bydgoszcz” report); 

• minimal and maximal costs of the CT; 

• assumption of the alternative cost of the CT, amounting 335.55 PLN – one or more 

parts of the body examination; 

• minimal and maximal costs of the palliative treatment; 

• minimal and maximal life expectancy, in case of lack of recurrence; 

• minimal and maximal life expectancy after palliative chemotherapy; 

- 

26



• minimal and maximal life expectancy in case of no treatment (delayed palliative 

chemotherapy) in case of wrong diagnosis; 

• minimal and maximal probabilities of gaining a positive result in the PET-CT and CT; 

• minimal and maximal probabilities of the correct recurrence diagnosis; 

• minimal and maximal probabilities of the correct diagnosis of no recurrence; 

• maximal probabilities of the wrong detection of recurrence and wrong detection of 

no recurrence. 

Sensitivity analysis results for the variable model parameters are shown in table below. 

Table 18. 

Sensitivity analysis of the PET-CT vs CT in the head and neck malignant neoplasm recurrences diagnostics 

Parameter 

Cost [PLN] 


Effect 

[years] 


Effect 

[years] 



Alternative PET-CT cost 3 943,61 3,354 2 853,46 3,224 8 385,77 

Minimal cost of CT 7 145,61 3,354 2 805,11 3,224 33 388,46 

Maximal cost of CT 7 145,61 3,354 2 904,61 3,224 32 623,08 

Alternative cost of CT 7 145,61 3,354 2 966,16 3,224 32 149,62 

Minimal cost of palliative 




Minimal survival in case of no 

recurrence 

Maximal survival in case of no 

recurrence 

5 655,21 3,354 1 363,06 3,224 33 016,54 

9 653,46 3,354 5 361,31 3,224 33 016,54 

7 145,61 2,762 2 853,46 2,656 40 491,98 

7 145,61 3,946 2 853,46 3,792 27 871,10 

Minimal survival after the 

palliative chemotherapy 7 145,61 3,318 2 853,46 3,197 35 472,31 

Maximal survival after the 

palliative chemotherapy 

Minimal survival after no 

treatment (delayed palliative 

chemotherapy) – wrong 

diagnosis 

Maximal survival after no 

treatment (delayed palliative 

chemotherapy) – wrong 

7 145,61 3,390 2 853,46 3,251 30 878,78 

7 145,61 3,349 2 853,46 3,208 30 440,78 

7 145,61 3,358 2 853,46 3,240 36 374,15 

27

diagnosis 

Minimal probability of PET-CT 

diagnostic procedure positive 

result 

Maximal probability of PET-CT 


result 

Minimal probability of CT 


result 

Maximal probability of CT 


result 



6 838,23 3,508 2 853,46 3,224 14 030,88 

7 452,99 3,199 2 853,46 3,224 

Dominated 

program 

7 145,61 3,354 2 546,08 3,304 91 990,60 

7 145,61 3,354 3 160,84 3,144 18 975,10 

Minimal probability of the 

correct recurrence detection 7 145,61 3,322 2 853,46 3,129 64 896,88 

Maximal probability of the 

correct recurrence detection 


wrong recurrence detection 


correct lack of recurrence 

detection 


correct lack of recurrence 

detection 


wrong lack of recurrence 

detection 

7 145,61 3,385 2 853,46 3,319 22 185,55 

7 145,61 3,322 2 853,46 3,129 64 896,88 

7 145,61 3,247 2 853,46 3,050 21 713,93 

7 145,61 3,460 2 853,46 3,398 69 772,90 

7 145,61 3,247 2 853,46 3,050 21 713,93 

Generally, the sensitivity analysis did not reveal any sudden costs and effects changes, for 

the mentioned parameters alterations, characterizing compared diagnostic schemes. Head 

and neck malignant neoplasms recurrences diagnostics using PET-CT remains more expensive 

and more effective than CT, only in case of assuming the maximal probability of the positive 

result in PET-CT, the program was dominated, i.e. PET-CT examination was more expensive 

and less efficient than computed tomography. The lowest ICER value was observed in case 

of assumption the alternative cost of PET-CT procedure on the level of 1,313.00 PLN (decrease 

of 74.60% from the baseline value). Maximal ICER ratio value was observed in case of 

assuming the minimal probability of gaining positive CT result (ICER increase of 178.62% from 

the baseline value). 

28



2.3. PRIMARY TUMOR DETECTION IN CASE OF CERVICAL LYMPH 

NODES METASTASES FROM THE UNKNOWN PRIMARY ORIGIN 

SQUAMOUS CELL CARCINOMA 


Model used in the cost-effectiveness analysis concerns group of patients with head and 

neck lymph nodes involved by the squamous cell carcinoma, undergoing imaging 

diagnostics to detect the primary tumor. PET-CT and CT diagnostics effects and costs were 













2.3.2. Model’s transient states 



• “Head and neck neoplasms” is a baseline state, characterizing patients population 



o Diagnosis: primary tumor (if the diagnostic procedure revealed primary head 

and neck malignant neoplasm); 

o Diagnosis: no primary tumor (if the primary head and neck malignant 

neoplasm was not detected). 

29



• “Diagnosis: primary tumor” – contains patients with diagnosed head and neck 

malignant neoplasms primary tumor. If the primary tumor is diagnosed, the two final 

states may occur: 

o Patient with primary tumor (in case of correct primary tumor diagnosis); 

o Patient without primary tumor (if the primary tumor was incorrectly diagnosed). 

• “Diagnosis: no primary tumor” – this state contains patients without diagnosed 

primary tumor of the head and neck malignant neoplasms. If no primary tumor was 


o Patient with primary tumor (if the lack of primary tumor was incorrectly 

diagnosed); 

o Patient without primary tumor (if the lack of primary tumor was correctly 

diagnosed). 

The figure below shows the illustration of the decision tree of the model, describing the 

course of head and neck malignant neoplasms primary tumor detection, using PET-CT and 

computed tomography. 

Figure 3. 

Decision tree showing the model used in calculations of PET-CT vs CT comparison, used in the diagnostics of the head 

and neck malignant neoplasms primary tumor (legend – table 24) 


tests had radical surgical and radiological and palliative treatment, patients with negative 

result had chemo-radiotherapy and palliative treatment. 

2.3.3. Costs calculation 



30






patient diagnostic procedures ranges (ASDW)”. Annex No. 1b to the informational materials 

AOS). Referrer covers the cost of performed procedure, according to the negotiated price of 

the point. The National Health Fund covers the cost of the co-financed diagnostic procedure, 

accordingly to the prices of the point, negotiated by: health care provider performing the 

procedure and by the referrer. 




PLN. 






Table 19. 




Computed 

tomography 





CT: CT of the head 

with the contrast 

media 

5.03.00.0000025 

NHF refund 


Referrer’s 

surcharge 


[PLN] 


dispensary 

Test 

cost 

(PLN) 

23 5 8,05 7,54 222,85 

PET-CT is an individually contracted service, amounting 420 points. The average price of 

the settlement point in positron emission tomography in the Center of Oncology in Bydgoszcz, 

the sole provider performing PET examination, amounts 10.75 PLN. 



31



Table 20. 


catalogue 









5.10.00.0000042 



[PLN] 

420 10,75 


4 515,00 






Table 21. 

Costs of the selected therapies from the NHF’s catalogue of services 



PF 








procedure =No 



[PLN] 

7 148,40 


PFH&N 

PFELVH&N 

PF1 











1–5 // 






25 mg/m 2 iv days 1–4 // 1000 mg/m 2 iv days 1- 




13 963,20 

6 376,80 

7 148,40 

3 636,00 

Table 22 contains selected radiotherapeutic procedures, from the NHF’s catalogue of 

services, used in head and neck malignant neoplasms treatment, as well as its cost. 

32



Table 22. 




procedure 








5.07.01.0000022 5 000 

5.07.01.0000023 8 000 




as cost of operative treatment of head and neck malignant neoplasms. 

Table 23. 

Surgical procedures used in head and neck malignant neoplasms treatment 












excision 















5.06.00.0000481 7 000 

5.06.00.0000682 5 200 

5.06.00.0000689 4 800 

5.06.00.0000479 7 000 

5.06.00.0000480 8 000 

5.06.00.0000482 5 000 

5.06.00.0000483 6 000 

5.06.00.0000484 4 500 

33

preservation 





5.06.00.0000134 2 000 





5.06.00.0000161 3 800 





2.3.4. Model parameters 


5.06.00.0000478 5 000 

Table 24. 

List of model parameters with values used in the sensitivity analysis of PET-CT vs CT comparison in the primary tumor 

of head and neck malignant neoplasms diagnostics 



[PLN] 


[PLN] 

Cost of palliative therapy (cPaliat2) 

[PLN] 

4 515,00 (1 313,00*) 222,85 (174,50; 274,00) 

7 148,40 (3 098,40; 13 963,20) 

7 148,40 (5 718,72; 8 578,08) 

Cost of chemotherapy (cChem) [PLN] 7 148,40** 

Cost of radiotherapy (cRT) [PLN] 5 000,00 (1 800,00; 8 000,00) 

Cost of radical therapy (cLeczRadyk) 

[PLN] 

Survival in case of lack of tumor or 

resective tumor (eP_LeczRadyk) 

[years] 

Survival in case of non-diagnosed 

tumor – wrong diagnosis 

(eP_GuzUkryty) [years] 



5 000,00 (2 000,00; 16 000,00) 

5,0 (4,0; 6,0) 

4,0 (3,0; 5,0) 

0,3680 (0,3249; 0,4111) 

34

Probability of the correct primary 

tumor detection (pTP) 

Probability of wrong primary tumor 

detection (pFP) 

Probability of correct lack of primary 

tumor detection (pTN) 

Probability of incorrect lack of 

primary tumor detection (pFN) 



0,9783 (0,9568; 0,9998) 0,7391 (0,6744; 0,8039) 

0,0217 (0,0002; 0,0432) 0,2609 (0,1961; 0,3256) 

0,9241 (0,8850; 0,9631) 0,7468 (0,6827; 0,8109) 

0,0759 (0,0369; 0,1150) 0,2532 (0,1891; 0,3173) 


Center of Oncology in Bydgoszcz” report); 

** only chemotherapeutic regimen used in “unknown primary origin neoplasms – squamous cell carcinoma” 

indication. 






• The average cost of head and neck malignant neoplasms radical treatment was 

assumed as equal to the cost of procedure 5.06.00.0000482 from the catalogue of the 

hospital services (the costs range between minimal and maximal cost of surgical 

procedures used in head and neck malignant tumors treatment – see: table 23). 

• As the average cost of palliative treatment (cPaliat) and chemotherapy (cChem), in 

case of no primary tumor, the cost of 6 cycles of PF chemotherapy (form the 

oncologic procedures catalogue) was assumed (the range between minimal and 

maximal cost of palliative chemotherapy, used in head and neck malignant tumors 

treatment – see: table 21). 

• Cost of the palliative treatment (cPaliat2) was assumed as equal to the cost of 6 

cycles of PF chemotherapy, from the oncologic services catalogue, used in unknown 

primary origin cancers treatment (range +/_ 1 cycle of treatment). 

• The average cost of unknown primary origin cancers involving cervical lymph nodes 

radiotherapy was assumed as the cost of procedure No. 5.07.01.0000022 from the 

oncologic services catalogue – teleradiotherapy, brachytherapy and isotope therapy 

(range between minimal and maximal cost of the procedures used in head and neck 

malignant neoplasms treatment – see table 23). 

• Minimal and maximal life expectancy values in case of detected primary tumor, real 

lack of primary tumor and in case of the primary tumor not detected with imaging 

35



studies, were assumed on a basis of the literature and estimation of experts from the 

Maria – Curie Skłodowska Memorial Institute Center of Oncology in Warsaw. 





used: 






computed tomography used in head and neck malignant neoplasms primary tumors 

diagnostics, where the average life expectancy expressed in years, was considered as the 

effect. Cohort simulation method was used in calculations. 

Table 25. 

Results of the cost-effectiveness analysis of the PET-CT vs CT in the head and neck malignant neoplasm primary 

tumor diagnostics 

Procedure 


patient [PLN] 


[PLN] 

Average life 

expectancy 

[years] 



4 292,15 

4,840 

Effects 

difference 

(LYG) 

ICER 

[PLN/LYG] 

0,112 38 322,77 

Cost-effectiveness analysis revealed, that head and neck malignant neoplasms of 

unknown primary origin diagnostics using PET-CT is more expensive than using computed 

tomography, but simultaneously gives a better long-term effect, measured with life years 

gained ratio. PET-CT cost included costs of the diagnostic procedure, surgical treatment and 

costs of palliative chemotherapy. The cost difference between diagnostic procedures 

amounts 4,292.15 PLN per one patient. Using PET-CT in one patient allows to gain 4.952 life 

years. In a group of patients, where computed tomography is performed, the anticipated 

effect amounts 4.840 life years. Difference of effects between PET-CT and CT amounts 0.112 

LYG (life years gained) i.e. approx. 41 days. 

36



Head and neck malignant neoplasms primary tumor diagnostics, using PET-CT system is 

more expensive, but more effective than computed tomography diagnostics. Incremental 

cost-effectiveness ratio amounts 38,322.77 PLN/LYG, that means, gaining one additional year 

of life using PET-CT diagnostics instead of CT, costs 38,322.77 PLN. 


100,000 patients. Results are shown in the table below. 

Table 26. 

Results of the Monte Carlo simulation analysis for 100,000 patients, comparing the PET-CT vs CT in the head and neck 

malignant neoplasm primary tumor diagnostics 

Parameter 



ICER 

[PLN/LYG] 

Average 21 190,30 4,951 16 898,15 4,840 38 668,02 



Median 23 811,80 5,000 19 519,65 5,000 

Maximal value 23 811,80 5,000 19 519,65 5,000 




0.111 of a life year. Median of the effect in a group of patient diagnosed using PET-CT 

amounts 5 life years, and in CT group – also 5 life years. Incremental cost-effectiveness ratio 

amounts 38,668.02 PLN/LYG that means, gaining one additional year of life using PET-CT 

diagnostics in head and neck malignant neoplasms primary tumor detection, instead of CT, 

costs 38,668.02 PLN. 


One-way sensitivity analysis of the PET-CT vs CT diagnostics in head and neck malignant 

neoplasms primary tumors detection was performed for the different model parameters; 

- 

37



• assumption the PET-CT cost on the level of 1,313.00 PLN (“subthreshold” PET-CT cost at 




• assumption of the alternative cost of the CT, amounting 335.55 PLN – one or more 

parts of the body examination; 

• minimal and maximal costs of the radical treatment; 

• minimal and maximal costs of the radiotherapy; 


• minimal and maximal costs of the palliative treatment (2); 

• minimal and maximal life expectancy, in case of lack of tumor or in case of resective 

tumor; 

• minimal and maximal life expectancy, in case of lack of tumor or in case of hidden 

tumor – wrong diagnosis; 


• maximal probability of the correct primary tumor detection; 

• minimal and maximal probabilities of the correct diagnosis concerning the lack of 

primary tumor. 


Table 27. 

Sensitivity analysis of the PET-CT vs CT in the head and neck malignant neoplasm primary tumor diagnostics 

Parameter 



Effect 

[years] 


Effect 

[years] 






Alternative cost of CT 21 181,19 4,952 17 001,74 4,840 37 316,52 

Minimal cost of radical 

treatment 

20 077,19 4,952 15 785,04 4,840 38 322,77 

38

Maximal cost of radical 

treatment 



25 229,19 4,952 20 937,04 4,840 38 322,77 

Minimal cost of radiotherapy 19 158,79 4,952 14 866,64 4,840 38 322,77 

Maximal cost of radiotherapy 23 077,19 4,952 18 785,04 4,840 38 322,77 






chemotherapy (2) 



19 528,86 4,952 15 139,39 4,840 39 191,70 

23 961,51 4,952 19 833,11 4,840 36 860,71 

20 334,79 4,952 16 077,00 4,840 38 015,98 

22 027,58 4,952 17 701,08 4,840 38 629,46 

Minimal survival in case of lack 

of tumor or resective tumor 21 181,19 4,000 16 889,04 4,000 

Maximal survival in case of lack 

of tumor or resective tumor 

Minimal survival in case of 

hidden tumor – wrong diagnosis 


program 

21 181,19 5,904 16 889,04 5,680 19 161,38 

21 181,19 4,904 16 889,04 4,680 19 161,38 

Maximal survival in case of 

hidden tumor – wrong diagnosis 21 181,19 5,000 16 889,04 5,000 

Minimal probability of PET-CT 


result 

Maximal probability of PET-CT 


result 

Minimal probability of CT 


result 

Maximal probability of CT 


result 


correct primary tumor detection 


correct lack of primary tumor 

detection 


correct lack of primary tumor 

detection 


program 

21 488,57 4,949 16 889,04 4,840 42 197,52 

20 873,81 4,955 16 889,04 4,840 34 650,17 

21 181,19 4,952 17 196,42 4,829 32 396,50 

21 181,19 4,952 16 581,66 4,851 45 539,90 

21 181,19 4,952 16 889,04 4,840 38 322,77 

21 181,19 4,927 16 889,04 4,799 33 570,71 

21 181,19 4,977 16 889,04 4,880 44 621,58 


the mentioned parameters alterations, characterizing compared diagnostic schemes. Head 

and neck malignant neoplasms primary tumors diagnostics using PET-CT remains more 

39



expensive and more effective than CT diagnostics, only if the minimal survival in case of lack 

of tumor or resective tumor is assumed or in case of the maximal survival of patients with 

hidden tumor (wrong diagnosis) the program was dominated, i.e. PET-CT diagnostics was 

more expensive and equally effective as CT diagnostics. The lowest ICER value was observed 

in case of assumption the alternative cost of PET-CT procedure on the level of 1,313.00 PLN 

(decrease of 74.60% from the baseline value). Maximal ICER ratio value was observed in case 

of assuming the maximal probability of gaining positive CT result (ICER increase of 18.83% from 

the baseline value). 

2.4. LITERATURE 

1. Branstetter IV BF, Blodgett TM, Zimmer LA, Snyderman CH, Johnson JT, Raman S, Meltzer CC. Head 

and neck malignancy: Is PET-CT more accurate than PET or CT alone?. Radiology 2005; Vol. 235 (2): 

pp 580–586. 

2. O'Malley BW, Chemotherapy and Radiation for Advanced Head and Neck Cancer, Baylor College 

of Medicine December 10, 1992. 

3. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant 

chemotherapy for locally advanced head and neck cancer. The New England Journal of Medicine 

6 May 2004; 350 (19): pp 1945–1952. 

4. Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy and chemotherapy 

for high-risk squamous-cell carcinoma of the head and neck. The New England Journal of Medicine 

6 May 2004; 350 (19): pp 1937–1944. 

5. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute 

(NCI) [http://seer.cancer.gov]. 

40



3. NON-SMALL CELL LUNG CANCER – COST-EFFECTIVENESS 

ANALYSIS – PET-CT VS CT DIAGNOSTICS 

In the cost-effectiveness analysis comparing the non-small cell lung cancer clinical 

advancement using PET-CT vs CT a decision model of preoperative non-small cell lung 

cancer staging (accordingly to the TNM scale) used to confirm or modify the planned 

treatment was used. 







lung cancer treatment, in a time horizon equal to patients’ life expectancy. 

3.1. MODEL DESCRIPTION 

Model used in the cost-effectiveness analysis concerns a group of patients with a non-small 

cell lung cancer, qualified, on a basis of the preliminary clinical assessment, to the surgical 

procedure. PET-CT and CT diagnostics effects and costs were compared. Decision model, 

using a TreeAge ® 2004 (version 7) software, was used in the analysis. Time horizon was 

estimated until patient’s death, cost data were estimated from the public payer’s 

perspective, on a basis of available information. The efficacy of the compared diagnostic 

methods was assessed in the clinical part of the report, entitled “Comparative cost – effect 

analysis of the positron emission tomography PET-CT with diagnostic technologies financed in 

Poland from the public assets in the oncologic diagnostics - epidemiological and clinical 

part”. Data concerning the treatment effects and consequences of the improper treatment, 

resulting from the misdiagnosing, were obtained from the literature or from experts' 





41

3.2. MODEL’S TRANSIENT STATES 





• “Non-small cell lung cancer” is a baseline state, characterizing patients’ population 



o Diagnosis: stage I (if the diagnostic procedure revealed stage I of the disease 

accordingly to the TNM scale); 

o Diagnosis: stage II (if the diagnostic procedure revealed stage II of the disease 


o Diagnosis: stage IIIA (if the diagnostic procedure revealed stage IIIA of the 

disease accordingly to the TNM scale); 

o Diagnosis: stage IIIB (if the diagnostic procedure revealed stage IIIB of the 


o Diagnosis: stage IV (if the diagnostic procedure revealed stage IV of the 


• “Diagnosis: stage I" – includes patients with preliminarily diagnosed I st stage of the 

disease, accordingly to the TNM scale. Patient diagnosed with I st stage of the disease, 

accordingly to the TNM scale, may pass to the following final states: 

o Patient in stage I (if the patient is in the I st stage of the disease, accordingly to 

the TNM scale); 

o Patient in stage II (if the patient is in the II nd stage of the disease, accordingly to 


o Patient in stage IIIA (if the patient is in the III rd A stage of the disease, 


o Patient in stage IIIB (if the patient is in the III rd B stage of the disease, 


o Patient in stage IV (if the patient is in the IV th stage of the disease, accordingly 

to the TNM scale). 

• “Diagnosis: stage II" – includes patients with preliminarily diagnosed II nd stage of the 

disease, accordingly to the TNM scale. Patient diagnosed with II nd stage of the 

disease, accordingly to the TNM scale, may pass to the following final states: 



42











• “Diagnosis: stadium IIIA” – obejmuje chorych, u których zdiagnozowano wystąpienie 

stadium IIIA choroby zgodnie ze skalą TNM. Patient diagnosed with III rd A stage of the 












• “Diagnosis: stage IIIB" – includes patients with preliminarily diagnosed III rd B stage of the 

disease, accordingly to the TNM scale. Patient diagnosed with III rd B stage of the 












43



• “Diagnosis: stage IV" – includes patients with preliminarily diagnosed IV th stage of the 

disease, accordingly to the TNM scale. Patient diagnosed with IV th stage of the 












The following figure shows the illustration of the decision tree of the model, describing the 

course of treatment patients who had the lung cancer clinical advancement diagnosed with 

PET-CT and computed tomography. 

44



Figure 4. 

Decision tree showing the model used in the calculations of PET-CT vs CT comparison, used in the non-small cell lung 

cancer clinical advancement assessment (legend – table 33) 

As presented in the figure 4, it is assumed that all patients with stage IIIA in diagnostic tests 

had surgical and chemotherapy treatment, all patients with stage IIIB result had chemo- 

radiotherapy, all patients with stage IV result had chemotherapy, patients correctly 

diagnosed as I and II stage had radical surgical treatment, underestimated as I and II stage 

patients with higher stages had surgical treatment and additionally chemotherapy. 

45

3.3. COSTS CALCULATION 



In a study concerning the lung cancer diagnostics, the hybrid PET-CT was compared to the 

computed tomography (CT). Computed tomography is and out-patient diagnostic service, 

co-financed (ASDW), that amounts 42 points – 37 points are refunded by the National Health 

Fund and the 5 points are covered by a physician referring to the procedure (“Catalogue of 

the co-financed out-patient diagnostic procedures ranges (ASDW)”. Annex No. 1b to the 

informational materials AOS). Referrer covers the cost of performed procedure, according to 

the negotiated price of the point. The National Health Fund covers the cost of the co- 

financed diagnostic procedure, accordingly to the prices of the point, negotiated by: health 

care provider performing the procedure and by the referrer. 




PLN. 

Similarly, the average point price in the computed tomography laboratory, calculated on a 

basis of the point price in all computed tomography laboratories bounded with the National 

Health Fund contract in Poland, amounts 8.05 PLN. 



Table 28. 




Computed 

tomography 




CT: One or more parts 

of the body 

examination - with 


5.03.00.0000029 

NHF refund 


Referrer’s 

surcharge 


[PLN] 

CT 

laboratory Oncologic 

dispensary 

37 5 8,05 7,54 

PET-CT is a individually contracted service of 420 points in pricing. The average price of the 





Test 

cost 

(PLN) 

335,55 

46



Table 29. 


catalogue 









5.10.00.0000042 



[PLN] 

420 10,75 


4 515,00 

The average CT examination cost in the diagnostics of the lung cancer amounts 335.55 PLN, 

and the PET-CT examination cost – from the public payer’s perspective – amounts 4,515.00 

PLN. 


calculate the costs of 4 or 6 cycles of palliative chemotherapy. 

Table 30. 

Costs of the selected chemotherapy regimens from the NHF’s catalogue of services 



PV 

KV 

PE 

PN 

KN 

PG 

KG 



VINBLASTINUM 

CARBOPLATINUM // 

VINBLASTINUM 


ETOPOSIDUM 

VINORELBINUM // CIS- 

PLATINUM 

VINORELBINUM // 

CARBOPLATINUM 

GEMCITABINUM // CIS- 

PLATINUM 

GEMCITABINUM 

//CARBOPLATINUM 

100 mg/m 2 iv day 1 // 5 mg/m 2 iv 

days 1 and 8 every 21 days 

300-350 mg/m 2 iv day 1 // 5 mg/m 2 

iv days 1 and 8 every 21 days 

30 mg/m 2 /day 1–3 or 80–100 

mg/m 2 iv day 1 // 100–120 

mg/m 2 /days 1–3 every 21 days 

25-30 mg/m 2 iv day 1 and 8 // 80- 

100 mg/m 2 iv day 1 every 21 days 

25-30 mg/m 2 iv day 1 and 8 every 

21 days// 300-350 mg/m 2 iv day 1 

1,250 mg/m 2 iv days 1 and 8 // 100 

mg/m 2 iv day 2 

1,000 mg/m 2 iv day 1 and 8// 300 

mg/m 2 iv day 2 every 21 days 


=No of points x point 

price (10 PLN) [PLN]* 

403,72–605,58 

417,72–626,58 

210,72–316,08 

563,24–844,86 

577,24–865,86 

1 506,92–2 260,38 

1 294,28–1 941,42 

*Cost intervals are presented accordingly to the quantity of applied chemotherapy cycles, 4 or 6 cycles 


services, used in lung cancer treatment, as well as its cost. 

47



Table 31. 




procedure 






5.07.01.0000023 8 000 



The table below contains selected procedures, from the NHF’s catalogue of services, 

including operative treatment of the lung cancer, as well as its cost. 

Table 32. 

Selected surgical procedures used in lung cancer treatment 


lungs/lung sleeve resection, pneumonectomy, 

sleeve lobectomy (anatomic resection with 

mediastinal lymphadenectomy) 

Lung resection – segmental lung resection, 

wedge lungs resection 

3.4. MODEL PARAMETERS 





5.06.00.0000368 12 000 

5.06.00.0000170 8 000 

Table 33. 

Comparison of model parameters with values used in the sensitivity analysis of PET-CT vs CT comparison in the 

clinical advancement of non-small cell lung cancer diagnostics 



[PLN] 

Cost of surgical treatment (cChir) 

[PLN] 

Cost of combined therapy with 

chemotherapy (cChir_Chem) [PLN] 

4 515,00 (1 313,00*) 335,55 (265,50; 414,00) 

12 000,00 (8 000,00**) 

22 603,80 (11 160,80; 34 603,80) 

48

Cost of chemotherapy combined with 

radiotherapy (cChem_RT) [PLN] 



13 632,40 (3 907,20; 23 069,20) 

Cost of chemotherapy (cChem) [PLN] 5 632,40 (2 107,20; 15 069,20) 

Survival of patients in stage (I) 

(eP_Stadium1) [years] 

Survival of patients in stage (I) treated 

incorrectly (eP_Stadium1minus) 

[years] 

Survival of patients in stage (II) 


Survival of patients in stage (II) 

treated incorrectly 

(eP_Stadium2minus) [years] 

Survival of patients in stage (IIIA) 

(eP_Stadium3A) [years] 



(eP_Stadium3Aminus) [years] 


treated incorrectly – worse prognosis 

(eP_Stadium3A2minus) [years] 

Survival of patients in stage (IIIB) 

(eP_Stadium3B) [years] 

Survival of patients in stage (IIIB) 


(eP_Stadium3Bminus) [years] 

Survival of patients in stage (IV) 


Probability of being classified, on a 

basis of the procedure, as a stage (I) 


basis of the procedure, as a stage (II) 


basis of the procedure, as a stage 

(IIIA) 


basis of the procedure, as a stage 

(IIIB) 


basis of the procedure, as a stage (IV) 

Probability of correct classification – 

stage (I) 


stage (II) 

4,0 (3,3; 5,5) 

1,0 (0,5; 1,5) 

2,2 (1,7; 2,7) 

1,0 (0,45; 1,4) 

1,4 (1,0; 1,7) 

1,0 (0,8; 1,6) 

0,7 (0,5; 0,9) 

0,76 (0,7; 0,83) 

0,5 (0,3; 0,8) 

0,5 (0,2; 0,6) 

0,3272 (0,3060; 0,3484) 0,3170 (0,2959; 0,3380) 

0,1539 (0,1376; 0,1702) 0,1718 (0,1547; 0,1888) 

0,1894 (0,1717; 0,2071) 0,1856 (0,1680; 0,2032) 

0,1894 (0,1717; 0,2071) 0,1856 (0,1680; 0,2032) 

0,1401 (0,1244; 0,1558) 0,1401 (0,1244; 0,1558) 

0,8563 (0,8404; 0,8721) 0,8323 (0,8154; 0,8492) 

0,4784 (0,4558; 0,5010) 0,4643 (0,4417; 0,4868) 

49


stage (IIIA) 


stage (IIIB) 


stage (IV) 

Probability of incorrect classification 

as a stage (I) – stage (II) 


as a stage (I) – stage (IIIA) 


as a stage (I) – stage (IIIB) 


as a stage (I) – stage (IV) 


as a stage (II) – stage (I) 


as a stage (II) – stage (IIIA) 


as a stage (II) – stage (IIIB) 


as a stage (II) – stage (IV) 


as a stage (IIIA) – stage (I) 



0,5452 (0,5227; 0,5677) 0,4959 (0,4733; 0,5185) 

0,5452 (0,5227; 0,5677) 0,4959 (0,4385; 0,5532) 

0,3066 (0,2857; 0,3274) 0,2482 (0,2286; 0,2677) 

0,4022 (0,3800; 0,4243) 0,3269 (0,3057; 0,3481) 

0,2772 (0,2569; 0,2974) 0,2981 (0,2774; 0,3188) 

0,2772 (0,2569; 0,2974) 0,2981 (0,2774; 0,3188) 

0,0435 (0,0343; 0,0527) 0,0769 (0,0649; 0,0890) 

0,3389 (0,3175; 0,3603) 0,3274 (0,3062; 0,3486) 

0,4636 (0,4411; 0,4862) 0,4429 (0,4204; 0,4653) 

0,4636 (0,4411; 0,4862) 0,4429 (0,4204; 0,4653) 

0,0727 (0,0610; 0,0845) 0,1143 (0,0999; 0,1287) 

0,7338 (0,7138; 0,7538) 0,7639 (0,7447; 0,7831) 


as a stage (IIIA) – stage (II) 0,2662 (0,2462; 0,2862) 0,2361 (0,2169; 0,2553) 


as a stage (IIIA) – stage (IIIB) 


as a stage (IIIA) – stage (IV) 

Probability of overestimation – 

diagnosed stage (IIIA) – probable 

stages (I) or (II) 


as a stage (IIIB) – stage (I) 


as a stage (IIIB) – stage (II) 


as a stage (IIIB) – stage (IIIA) 

0,8644 (0,8489; 0,8799) 0,7949 (0,7766; 0,8131) 

0,1356 (0,1201; 0,1511) 0,2051 (0,1869; 0,2234) 

0,3752 (0,3533; 0,3971) 0,3967 (0,3746; 0,4188) 

0,6201 (0,5981; 0,6420) 0,6286 (0,6067; 0,6504) 

0,2249 (0,2060; 0,2438) 0,1943 (0,1764; 0,2122) 

0,1550 (0,1386; 0,1714) 0,1771 (0,1599; 0,1944) 


as a stage (IIIB) – stage (IV) 0,0108 (0,0061; 0,0155) 0,0220 (0,0154; 0,0287) 

Probability of incorrect classification 0,5368 (0,5143; 0,5594) 0,5340 (0,5114; 0,5565) 

50

as a stage (IV) – stage (I) 


as a stage (IV) – stage (II) 


as a stage (IV) – stage (IIIA) 


as a stage (IV) – stage (IIIB) 



0,1947 (0,1768; 0,2126) 0,1650 (0,1483; 0,1818) 

0,1342 (0,1188; 0,1496) 0,1505 (0,1343; 0,1667) 

0,1342 (0,1188; 0,1496) 0,1505 (0,1343; 0,1667) 



**Cost of alternative surgical treatment (procedure No. 5.06.00.0000170 – see table 5) 




• The average CT cost amounts 335.55; minimal cost of this procedure amounted 265 


• The average cost of lung cancer surgical treatment was assumed as equal to the cost 

of procedure No. 5.06.00.0000368 from the hospital services catalogue (alternative 

cost of surgical treatment was assumed as equal to the cost of procedure No. 

5.06.00.0000170 – see table 32). 

• The average cost of lung cancer surgical treatment with neoadiuvant and adiuvant 

chemotherapy was assumed as equal to the cost of procedure No. 5.06.00.0000368 

from the hospital services catalogue (alternative cost of surgical treatment was 

assumed as equal to the cost of procedure No. 5.06.00.0000170 – see table 32) and 

the cost of 2 cycles of neoadiuvant and 4 cycles of adiuvant PN chemotherapy from 

the oncologic services catalogue (range of costs between minimal and maximal cost 

of non-small cell lung cancer chemotherapy – see table 30). 

• The average cost of lung cancer radiotherapy with chemotherapy was assumed as 

equal to the cost of procedure 5.07.01.0000023 from the catalogue of oncologic 

services (range of costs between minimal and maximal cost of non-small cell lung 

cancer radiotherapy – see table 31) and the cost of 4 cycles of adiuvant PN 

chemotherapy from the oncologic services catalogue (range of costs between 

minimal and maximal cost of non-small cell lung cancer chemotherapy – see table 

30). 

• As the average cost of chemotherapy, the cost of 4 cycles PN chemotherapy from 

the catalogue of oncologic services was assumed (range of costs between minimal 

51



and maximal cost of chemotherapy regimens used in non-small cell lung cancer 

treatment – see table 30). 

• Life expectancy in particular stages of the disease and their minimal and maximal 

values were assumed on a basis of the literature or estimation of experts from the 

Maria Skłodowska – Curie Memorial Institute, Center of Oncology in Warsaw. 





used: 

3.5. RESULTS 

o Cerfolio RJ, Bryant AS, Ojha B, Eloubeidi M. Improving the inaccuracies of 

clinical staging of patients with NSCLC: A prospective trial. Ann Thora Surg 

2005; Vol. 80 (4): pp 1207–1214. 

o Shim SS, Lee KS, Kim BT, Chung MJ, Lee EJ, Han J, Choi JY, Kwon OJ, Shim YM, 

Kim S. Non-small cell lung cancer: prospective comparison of integrated FDG 

PET-CT and CT alone for preoperative staging. Radiology 2005 Sep; 236 (3): pp 

1011–1019. Epub 2005 Jul 12. 


computed tomography used in non-small cell lung cancer clinical advancement assessment, 

where the average life expectancy, expressed in years, was considered as the effect. Cohort 

simulation method was used in calculations. 

Table 34. 

Results of the cost-effectiveness analysis of the PET-CT vs CT in the non-small cell lung cancer clinical advancement 

assessment 

Procedure 


patient [PLN] 


[PLN] 

Average 

lifetime 

expectancy 

[years] 



4 127,28 

2,227 

Effects 

difference 

(LYG) 

ICER 

[PLN/LYG] 

0,027 152 862,22 

52



Cost-effectiveness analysis revealed, that diagnostics of non-small cell lung cancer clinical 

advancement using PET-CT is more expensive than using computed tomography, but 

simultaneously gives a better long-term effect, measured with life years gained ratio. Costs of 

PET-CT and CT included costs of the diagnostic procedure, surgical treatment and costs of 

palliative chemotherapy. The cost difference between diagnostic procedures amounts 

4,127.28 PLN per one patient. Using PET-CT in one patient allows to gain 2.254 life years. In a 

group of patients, where computed tomography was performed, the anticipated health 

effect amounts 2.227 life years. Difference of effects between PET-CT and CT amounts 0.027 

LYG (life years gained) i.e. approx. 10 days. 

Diagnostics of non-small cell lung cancer clinical advancement, using PET-CT system is more 






Table 35. 

Results of the Monte Carlo simulation analysis for 100,000 patients, comparing the PET-CT vs CT in the diagnostics of 

non-small cell lung cancer clinical advancement 

Parameter 



ICER 

[PLN/LYG] 

Average 17 611,12 2,256 13 488,59 2,228 147 233,21 



Median 16 515,00 1,400 12 335,55 1,400 

Maximal value 22 147,40 4,000 17 967,95 4,000 


cohort simulation method. Assessment of non-small cell lung cancer clinical advancement 

using PET-CT method remains more expensive and more effective than using computed 

tomography only. Difference of effects averages amounts 0.028 of a life year. Median of the 

effect in a group of patients diagnosed using PET-CT and CT amount 1.4 life years. 

Incremental cost-effectiveness ratio amounts 147,233.21 PLN/LYG that means, gaining one 

- 

53



additional year of life using PET-CT diagnostics of non-small cell lung cancer clinical 

advancement assessment, instead of CT, costs 147,233.21 PLN. 

3.6. SENSITIVITY ANALYSIS 

One-way sensitivity analysis of PET-CT vs CT comparison in the non-small cell lung cancer 

clinical assessment, was conducted for various model parameters: 





• assumption of the alternative cost of the surgical treatment amounting 8,000.00 PLN; 

• minimal and maximal costs of the surgical treatment combined with chemotherapy; 

• minimal and maximal costs of the chemotherapy; 

• minimal and maximal costs of the surgical treatment combined with radiotherapy; 

• minimal and maximal life expectancy of patients with stage (I), (II), (IIIA), (IIIB) and (IV) 

of the disease; 

• minimal and maximal life expectancy of patients with stage (I), (II), (IIIA), (IIIB) of the 

disease in a group of incorrectly treated patients; 

• minimal and maximal life expectancy of patients with stage (IIIA) of the disease in a 

group of incorrectly treated patients with worse prognosis. 

Two-way sensitivity analysis of PET-CT vs CT comparison in the non-small cell lung cancer 

clinical assessment, was conducted for various model parameters: 

• minimal and maximal probabilities of classification using the procedure as stage (I), 

(II), (IIIA), (IIIB), (IV); 

• minimal and maximal probabilities of correct classification as stage (I), (II), (IIIA), (IIIB), 

(IV); 

• minimal and maximal probabilities of incorrect classification as a stage (I) in stage (II), 

(IIIA), (IV); 

• minimal and maximal probabilities of incorrect classification as a stage (II) in stage (I); 

• minimal probabilities of incorrect classification as a stage (II) in stage (IIIA); 

54



• maximal probabilities of incorrect classification as a stage (IIIA) in stage (I); 

• minimal and maximal probabilities of incorrect classification as a stage (IV) in stage (I). 


Table 36. 

Sensitivity analysis of the comparison PET-CT vs CT in the non-small cell lung cancer clinical advancement 

assessment 

Parameter 



Effect 

[years] 


Effect 

[years] 

ICER 

[PLN/LYG] 





Alternative cost of surgical 

treatment 

Minimal cost of surgical treatment 

combined with chemotherapy 

Maximal cost of surgical treatment 

combined with chemotherapy 

15 700,31 2,254 11 542,23 2,227 154 002,96 

16 055,00 2,254 11 959,21 2,227 151 695,93 

18 790,51 2,254 14 639,83 2,227 153 728,89 

Minimal cost of chemotherapy 16 932,63 2,254 12 751,25 2,227 154 865,93 

Maximal cost of chemotherapy 19 477,39 2,254 15 494,90 2,227 147 499,63 

Minimal cost of chemotherapy 

combined with radiotherapy 

Maximal cost of chemotherapy 

combined with radiotherapy 

Minimal survival of patients in stage 

(I) 

Maximal survival of patients in 

stage (I) 

Minimal survival of incorrectly 

treated patients in stage (I) 

Maximal survival of incorrectly 

treated patients in stage (I) 

15 249,37 2,254 11 171,00 2,227 151 050,74 

18 878,65 2,254 14 725,55 2,227 153 818,52 

17 624,71 1,985 13 497,43 1,963 187 603,64 

17 624,71 2,831 13 497,43 2,791 103 182,00 

17 624,71 2,202 13 497,43 2,171 133 138,06 

17 624,71 2,307 13 497,43 2,283 171 970,00 


(II) 17 624,71 2,199 13 497,43 2,169 137 576,00 


stage (II) 

17 624,71 2,310 13 497,43 2,284 158 741,54 

55


treated patients in stage (II) 


treated patients in stage (II) 


(IIIA) 


stage (IIIA) 


treated patients in stage (IIIA) 


treated patients in stage (IIIA) 


treated patients in stage (IIIA) – 

worse prognosis 


treated patients in stage (IIIA) – 

worse prognosis 


(IIIB) 


stage (IIIB) 



17 624,71 2,234 13 497,43 2,208 158 741,54 

17 624,71 2,270 13 497,43 2,241 142 320,00 

17 624,71 2,213 13 497,43 2,190 179 446,96 

17 624,71 2,285 13 497,43 2,254 133 138,06 

17 624,71 2,249 13 497,43 2,220 142 320,00 

17 624,71 2,275 13 497,43 2,252 179 446,96 

17 624,71 2,249 13 497,43 2,220 142 320,00 

17 624,71 2,260 13 497,43 2,233 152 862,22 

17 624,71 2,246 13 497,43 2,218 147 402,86 

17 624,71 2,264 13 497,43 2,237 152 862,22 


treated patients in stage (IIIB) 17 624,71 2,252 13 497,43 2,224 147 402,86 


treated patients in stage (IIIB) 


(IV) 


stage (IV) 

Minimal probability of being 

classified, on a basis of the 

procedure, as a stage (I) 

Maximal probability of being 


procedure, as a stage (I) 



procedure, as a stage (II) 



procedure, as a stage (II) 



procedure, as a stage (IIIA) 

17 624,71 2,258 13 497,43 2,232 158 741,54 

17 624,71 2,239 13 497,43 2,211 147 402,86 

17 624,71 2,260 13 497,43 2,232 147 402,86 

17 708,76 2,195 13 577,88 2,170 165 235,20 

17 540,66 2,313 13 417,36 2,283 137 443,33 

17 680,45 2,226 13 553,44 2,198 147 393,21 

17 568,97 2,282 13 441,75 2,255 152 860,00 

17 624,71 2,231 13 497,43 2,203 147 402,86 

56



procedure, as a stage (IIIA) 



procedure, as a stage (IIIB) 



procedure, as a stage (IIIB) 



procedure, as a stage (IV) 



procedure, as a stage (IV) 


classification – stage (I) 


classification – stage (I) 


classification – stage (II) 


classification – stage (II) 


classification – stage (IIIA) 


classification – stage (IIIA) 



17 624,71 2,277 13 497,43 2,250 152 862,22 

17 624,71 2,254 13 497,43 2,227 152 862,22 

17 624,71 2,254 13 497,43 2,227 152 862,22 

17 794,53 2,256 13 667,24 2,228 147 403,21 

17 454,90 2,253 13 327,61 2,226 152 862,59 

17 649,72 2,235 13 526,51 2,206 142 179,66 

17 599,81 2,274 13 468,46 2,248 158 898,08 

17 675,42 2,242 13 553,94 2,213 142 120,00 

17 574,00 2,266 13 440,92 2,240 158 964,62 

17 624,71 2,247 13 497,43 2,219 147 402,86 

17 624,71 2,262 13 497,43 2,234 147 402,86 


classification – stage (IIIB) 17 624,71 2,256 13 497,43 2,229 152 862,22 


classification – stage (IIIB) 


classification – stage (IV) 


classification – stage (IV) 

Minimal probability of incorrect 

classification as a stage (I) – stage 

(II) 



(II) 



(IIIA) 



17 624,71 2,252 13 497,43 2,225 152 862,22 

17 624,71 2,259 13 497,43 2,231 147 402,86 

17 624,71 2,249 13 497,43 2,222 152 862,22 

17 630,59 2,253 13 503,78 2,225 147 386,07 

17 618,86 2,256 13 491,08 2,228 147 420,71 

17 624,71 2,254 13 497,43 2,226 147 402,86 

17 624,71 2,255 13 497,43 2,227 147 402,86 

57

(IIIA) 



(IV) 



(IV) 


classification as a stage (II) – stage 

(I) 



(I) 



(IIIA) 


classification as a stage (IIIA) – 

stage (I) 


classification as a stage (IV) – stage 

(I) 


classification as a stage (IV) – stage 

(I) 



17 624,71 2,255 13 497,43 2,227 147 402,86 

17 624,71 2,254 13 497,43 2,227 152 862,22 

17 643,26 2,244 13 517,94 2,215 142 252,41 

17 606,16 2,265 13 476,91 2,238 152 935,19 

17 624,71 2,254 13 497,43 2,227 152 862,22 

17 624,71 2,257 13 497,43 2,229 147 402,86 

17 624,71 2,253 13 497,43 2,226 152 862,22 

17 624,71 2,256 13 497,43 2,228 147 402,86 


the mentioned parameters alterations, characterizing compared diagnostic schemes. Non- 

small cell lung cancer clinical advancement assessment, using PET-CT system, remains more 

expensive, but simultaneously more effective than computed tomography diagnostics. The 

lowest ICER value was observed in case of assumption the alternative cost of PET-CT 

procedure on the level of 1,313.00 PLN (decrease of 77.58% from the baseline value). 

Maximal ICER ratio value was observed in case of assuming the minimal life expectancy of 

patient in stage (I) of the disease (ICER increase of 22.73% from the baseline value). 


1. Cerfolio RJ, Bryant AS, Ojha B, Eloubeidi M. Improving the inaccuracies of clinical staging of patients 

with NSCLC: A prospective trial. Ann Thora Surg 2005; Vol. 80 (4): pp 1207–1214. 

2. Shim SS, Lee KS, Kim BT, Chung MJ, Lee EJ, Han J, Choi JY, Kwon OJ, Shim YM, Kim S. Non-small cell 

lung cancer: prospective comparison of integrated FDG PET-CT and CT alone for preoperative 

staging. Radiology 2005 Sep; 236 (3): pp 1011–1019. Epub 2005 Jul 12. 

58





4. Jahan TM, Glassberg AB, Cornett P, Haas-Kogan D, Anastassiou P, Selim S, Jablons D. Non-Small Cell 

Lung Cancer. Cancer Supportive Care [http://www.cancersupportivecare.com/nonsmallcell.html]. 

5. Szczeklik A. Choroby wewnętrzne. Medycyna Praktyczna, Kraków 2006. 

59



4. GASTROINTESTINAL STROMAL TUMORS (GIST) – COST- 

EFFECTIVENESS ANALYSIS –PET-CT VS CT DIAGNOSTICS 

In the cost-effectiveness analysis comparing assessment of response to imatinib treatment in 

patients with gastrointestinal stromal tumors (GIST) using PET-CT and CT, a decision model was 

used, concerning the assessment of patients treated with imatinib due to the GIST, aiming to 

early detection of possible recurrences and to modify planned treatment. 






perspective were assumed on a basis of the available data concerning procedures used in 

GIST treatment, in a time horizon equal to patients’ life expectancy. 


Model used in the cost-effectiveness analysis concerns a group of patients with 

gastrointestinal stromal tumor (GIST), qualified, on a basis of the preliminary clinical 

assessment, to the imatinib treatment and disqualified from the surgical procedure. PET-CT 

and CT diagnostics effects and costs were compared. Decision model, using a TreeAge ® 

2004 (version 7) software, was used in the analysis. Time horizon was estimated until patient’s 

death, cost data were estimated from the public payer’s perspective, on a basis of available 

information. The efficacy of the compared diagnostic methods was assessed in the clinical 

part of the report, entitled “Comparative cost – effect analysis of the positron emission 

tomography PET-CT with diagnostic technologies financed in Poland from the public assets in 

the oncologic diagnostics - epidemiological and clinical part”. Data concerning the 

treatment effects and consequences of the improper treatment, resulting from the 

misdiagnosing, were obtained from the literature or from experts' estimation, in case of 

unavailable data. 




60






• “GIST" is a baseline state, characterizing population of patients with gastrointestinal 

stromal tumor treated with imatinib. After the diagnostic procedure, there is a 

possibility to pass into the following states: 

o Diagnosis: response to treatment (if the diagnostic procedure revealed 

response to imatinib treatment in patients with GIST); 

o Diagnosis: progression (if the diagnostic procedure revealed a disease 

progression in patients with GIST treated with imatinib). 

• “Diagnosis: response to treatment” – contains patients with GIST who, on a basis of 

imaging procedures, responded to imatinib treatment. Patient diagnosed as a 

responder to treatment may pass to the following final states: 

o Response to treatment (if there is a response to imatinib treatment); 

o Progression (if there is a progression of the disease after imatinib treatment). 

• “Diagnosis: progression” – contains patients with diagnosed progression of the 

gastrointestinal stromal tumor. Patient with a diagnosed progression may pass to the 

following final states: 

o Response to treatment (if there is a response to imatinib treatment); 

o Progression (if there is a progression of the disease after imatinib treatment). 

The following figure shows the illustration of the decision tree of the model, describing the 

course of treatment patients with a gastrointestinal stromal tumor (GIST) who had a response 

to imatinib treatment assessed using PET-CT or computed tomography. 

61



Figure 5. 

Decision tree showing the model used in the calculations of PET-CT vs CT comparison, used to assess the response for 

imatinib treatment of GIST (legend – table 40) 

As presented in the figure 5, it is assumed that all patients had imatinib treatment. 


In a study concerning the gastrointestinal stromal tumor diagnostics, the hybrid PET-CT was 

compared to the computed tomography (CT). Computed tomography is and out-patient 

diagnostic service, co-financed (ASDW), that amounts 42 points – 37 points are refunded by 

the National Health Fund and the 5 points are covered by a physician referring to the 

procedure (“Catalogue of the co-financed out-patient diagnostic procedures ranges 

(ASDW)”. Annex No. 1b to the informational materials AOS). Referrer covers the cost of 

performed procedure, according to the negotiated price of the point. The National Health 

Fund covers the cost of the co-financed diagnostic procedure, accordingly to the prices of 

the point, negotiated by: health care provider performing the procedure and by the referrer. 




PLN. 






62



Table 37. 




Computed 

tomography 








5.03.00.0000029 

NHF refund 


Referrer’s 

surcharge 


[PLN] 



dispensary 

37 5 8,05 7,54 






Table 38. 


catalogue 









5.10.00.0000042 



[PLN] 

Test 

cost 

(PLN) 

335,55 


420 10,75 4 515,00 

The average CT examination cost in the diagnostics of the gastrointestinal stromal tumor 

(GIST) amounts 335.55 PLN, and the PET-CT examination cost – from the public payer’s 


Cost of the imatinib treatment of gastrointestinal stromal tumor was calculated on a basis of 

the “Catalogue of therapeutic programs” (Annex 1d to the Fund President’s resolution No 

12/2006 and annex No 9 to the resolution No 93/2005 worded as specified in annex No 5 to 

the Fund President’s resolution No 12/2006). Cost of imatinib is presented in the following 

table. 

Table 39. 

Active substance used in GIST treatment and its point value on a basis of the therapeutic programs catalogue 


Cost of imatinib = points 

valuation x point price (10 

PLN) [PLN] 

63

IMATINIB 

CAPS. 0.1 G 





5.08.04.0000036 77,50 

Table 40. 

Comparison of model parameters with values used in the sensitivity analysis of PET-CT vs CT comparison in the 

assessment of GIST response to imatinib treatment 



[PLN] 4 515,00 (1 313,00*) 335,55 (174,50; 274,00) 

Cost of treatment patient responding 

to the therapy (cChem_R) [PLN] 

Cost of treatment patient with 

progression (cChem_PD) [PLN] 

Survival of patients responding to 

treatment (eP_R) [years] 

Survival in case of wrong diagnosis 

(eP_Rminus) [years] 

Survival of patients with progression 

(eP_PD) [years] 

Probability of obtaining test result 

ascertaining response to treatment 

Probability of obtaining the correct 

result ascertaining response to 

treatment 

Probability of obtaining correct result 

ascertaining disease progression 

193 130,00 (132 432,00; 331 080,00) 

27 590,00 (22 072,00; 55 180,00) 

1,75 (1,2; 3,0) 

0,5 (0,3; 1,0) 

0,25 (0,2; 0,25) 

0,8500 (0,7702; 0,9298) 0,4500 (0,3388; 0,5612) 

0,9412 (0,8886; 0,9938) 0,7778 (0,6848; 0,8707) 

1** 0,1818 (0,0956; 0,2681) 



**It was assumed that the result will always be correct if the PET-CT reveals presence of the lesion. 






64



• The average cost of treating patient responding to the therapy was equal to the cost 

of treatment with 400 mg imatinib per day, until progression – for 17 months (treatment 

timeframe equal to the survival timeframes minus three months) (cChem_R). 

• The average cost of treating patient with a progression was equal to the cost of 

treatment with 400 mg imatinib per day, until death – for 6 months (upper and lower 

interval, equal to the survival intervals) (cChem_PD). 

• Life expectancy in patients responding to therapy, with progression or with response 

to therapy in case of wrong diagnosis and its minimal and maximal values were 

implemented on a basis of the literature and opinion of experts from the Maria 

Skłodowska – Curie Memorial Institute, Center of Oncology in Warsaw. 

• Values of the parameters concerning tests accuracy were taken from the report 

entitled “Comparative cost – effect analysis of the positron emission tomography PET- 

CT with diagnostic technologies financed in Poland from the public assets in the 

oncologic diagnostics - epidemiological and clinical part”. Information from the 

following publications were used: 

4.5. RESULTS 

o Antoch G, Kanja J, Bauer S, Kuehl H, Renzing-Koehler K, Schuette J, Bockisch A, 

Debatin JF, Freudenberg LS. Comparison of PET, CT, and dual-modality PET-CT 

imaging for monitoring of imatinib (STI571) therapy in patients with 

gastrointestinal stromal tumors. J Nucl Med 2004 Mar; 45 (3): pp 357–365. 


computed tomography used in assessment the response for gastrointestinal stromal tumor, 

where the average lifetime expectancy expressed in years, was considered as the effect. 


Table 41. 

List of the cost-effectiveness analysis results concerning comparison of PET-CT vs CT in the assessment of the GIST 

treatment with imatinib response 

Procedure 


patient [PLN] 


[PLN] 

Average 

lifetime 

expectancy 

[years] 



89 710,10 

0,888 

Effects 

difference 

(LYG) 

ICER 

[PLN/LYG] 

0,562 159 626,51 

65



The analysis revealed, that gastrointestinal stromal tumors response to treatment assessment 

using PET-CT is more expensive than using computed tomography, but simultaneously gives a 

better long-term effect, measured with life years gained ratio. Costs of PET-CT and CT 

included costs of the diagnostic procedure and costs of chemotherapy until progression. The 

costs difference between diagnostic procedures amounts 89,710.10 PLN per one patient. 

Using PET-CT in one patient allows to gain 1.450 life years. In a group of patients, where 

computed tomography was performed, the anticipated health effect amounts 0.888 life 

year. Difference of effects between PET-CT and CT amounts 0.562 LYG (life years gained) i.e. 

approx. 205 days. 

Assessment of GIST response to imatinib therapy, using PET-CT system is more expensive, but 

more effective than computed tomography diagnostics. Incremental cost-effectiveness ratio 


diagnostics instead of CT, costs 159,626.51 PLN. 



Table 42. 

Results of the Monte Carlo simulation analysis for 100,000 patients, comparing the PET-CT vs CT in the GIST response 

to imatinib assessment 

Parameter 



ICER 

[PLN/LYG] 

Average 160 093,35 1,447 70 333,04 0,886 160 000,55 


Minimal value 4 515,00 0,250 335,55 0,250 

Median 197 645,00 1,750 335,55 0,500 

Maximal value 197 645,00 1,750 193 465,55 1,750 


cohort simulation method. Assessment of gastrointestinal stromal tumor (GIST) response to 

imatinib treatment using PET-CT remains more expensive and more effective strategy than 

using computed tomography. Difference of effects averages amounts 0.561 of a life year. 

Median of the effect in a group of patient diagnosed using PET-CT amounts 1.75 life years, 

and in a group of patients diagnosed with CT, the median of effect amounts 0.5 life year. 

Incremental cost-effectiveness ratio amounts 160,000.55 PLN/LYG that means, gaining one 

- 

66



additional year of life using PET-CT diagnostics to assess the GIST response to imatinib therapy, 

instead of CT, costs 160,000.55 PLN. 


One-way sensitivity analysis of comparison PET-CT vs CT in gastrointestinal stromal tumor 

(GIST) response to treatment was conducted for various model parameters: 





• minimal and maximal costs of treatment patients responding to the therapy; 

• minimal and maximal costs of treatment patients with a disease progression; 

• minimal and maximal survival of patients responding to the therapy and patients with 

the disease progression; 

• minimal and maximal life expectancy of patients responding to treatment in case of 

wrong diagnosis; 

• minimal and maximal probabilities of obtaining test result ascertaining response to 

treatment 

• minimal and maximal probabilities of obtaining correct test result ascertaining 

response to treatment 

• minimal and maximal probabilities of the correct diagnosis of progression; 


Table 43. 

Sensitivity analysis of comparison of PET-CT vs CT in the assessment of GIST response to imatinib treatment 

Parameter 








67

Minimal cost of patient 

responding to therapy 

treatment 

Maximal cost of patient 

responding to therapy 

treatment 

Minimal cost of patient 

with progression 

treatment 

Maximal cost of patient 

with progression 

treatment 

Minimal survival of 

patients responding to 

the therapy 

Maximal survival of 


the therapy 



therapy in case of 

wrong diagnosis 



therapy in case of 



patients with progression 


patients with progression 

Minimal probability of 

obtaining test result 

ascertaining response to 

treatment 

Maximal probability of 

obtaining test result 

ascertaining response to 

treatment 


obtaining the correct 

result ascertaining 



obtaining the correct 

result ascertaining 



obtaining correct result 

ascertaining disease 

progression 



111 842,20 1,450 49 446,80 0,888 111 023,84 

270 764,57 1,450 118 975,58 0,888 270 087,17 

160 126,02 1,450 70 139,96 0,888 160 117,54 

161 780,76 1,450 73 450,43 0,888 157 171,41 

160 401,81 1,010 70 691,71 0,695 284 793,97 

160 401,81 2,450 70 691,71 1,325 79 742,31 

160 401,81 1,450 70 691,71 0,798 137 592,18 

160 401,81 1,450 70 691,71 1,113 266 202,08 

160 401,81 1,440 70 691,71 0,878 159 626,51 

160 401,81 1,500 70 691,71 0,938 159 626,51 

145 766,79 1,337 53 305,92 0,781 166 296,53 

175 036,83 1,563 88 077,49 0,995 153 097,43 

153 000,52 1,383 63 763,86 0,825 159 922,33 

167 803,10 1,517 77 612,11 0,950 159 067,00 

160 401,81 1,452 70 691,71 0,899 162 224,41 

68


obtaining correct result 

ascertaining disease 

progression 



160 401,81 1,450 70 691,71 0,876 156 289,37 

Sensitivity analysis revealed stability of the performed calculations for the described 

alterations of parameters, characterizing compared diagnostic schemes. Assessment of GIST 

response to treatment using PET-CT remains more expensive but simultaneously more 

effective than CT diagnostics. Minimal ICER value was observed in case of maximal life 

expectancy of patients responding to therapy assumption (decrease of 50.04% from the 

baseline value). Maximal ICER ratio value was observed in case of assuming the minimal life 

expectancy of patient responding to therapy (ICER increase of 78.41% from the baseline 

value). 

69




1. Antoch G, Kanja J, Bauer S, Kuehl H, Renzing-Koehler K, Schuette J, Bockisch A, Debatin JF, 

Freudenberg LS. Comparison of PET, CT, and dual-modality PET-CT imaging for monitoring of 

imatinib (STI571) therapy in patients with gastrointestinal stromal tumors. J Nucl Med 2004 Mar; 45 (3): 

pp 357–365. 



3. DeMatteo RP, Lewis JJ, Leung D, Mudan SS, Woodruff JM, Brennan MF. Two hundred gastrointestinal 

stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg. 2000 Jan; 231 (1): 

pp 51–58. 

4. Verweij J, Casali PG, Zalcberg J, LeCesne A, Reichardt P, Blay JY, Issels R, van Oosterom A, 

Hogendoorn PC, Van Glabbeke M, Bertulli R, Judson I. Progression-free survival in gastrointestinal 

stromal tumours with high-dose imatinib: randomised trial. Lancet. 2004 Sep 25-Oct 1; 364 (9440): pp 

1127–1134. 

70



5. UNKNOWN PRIMARY ORIGIN DETECTION IN CASE OF 

CERVICAL LYMPH NODES INVOLVEMENT BY THE SQUAMOUS CELL 

CANCER – COST-EFFECTIVENESS ANALYSIS – PET-CT VS CT 

In the cost-effectiveness analysis comparing unknown primary origin cancers diagnostics 

with PET-CT and CT, a decision model concerning the diagnostics performed in case of 

cervical lymph nodes involvement by squamous cell carcinoma, aiming to detect the 

primary origin of the cancer, was used. 




diagnostics - epidemiological and clinical part”. Due to the possibility of constructing the 

model, only the results concerning the population of patients with cervical lymph nodes 

involved by squamous cell carcinoma, most commonly resulting from the head and neck 

malignant neoplasm (such patient comprise 2/3 of studied population), patients with 

metastases to other regions were excluded due to the difficulty in compilation homogenous 

cost data for the differentiated primary neoplasms. Clinical effects were estimated on a basis 

of available data from studies or experts’ estimations. Costs, from the Polish public payer’s 


particular indications, in a time horizon equal to patients’ survival. 


Model used in the cost-effectiveness analysis concerns group of patients with head and 

neck lymph nodes involved by the squamous cell carcinoma, undergoing imaging 

diagnostics to detect the primary tumor. PET-CT and CT diagnostics effects and costs were 










71









• “Unknown primary origin neoplasms” is a baseline state, characterizing patients 

population at the beginning of treatment. After the diagnostic procedure, there is a 

possibility to pass into the following states: 

o Diagnosis: primary tumor (if the diagnostic procedure revealed primary tumor 

of the unknown primary origin neoplasm); 

o Diagnosis: no primary tumor (if the primary tumor of the unknown primary origin 

neoplasm was not detected). 

• “Diagnosis: primary tumor” – contains patients with detected primary tumor of the 

unknown primary origin neoplasms. If the primary tumor is diagnosed, the two final 

states may occur: 

o Patient with primary tumor (in case of correct primary tumor diagnosis); 

o Patient without primary tumor (if the primary tumor was incorrectly diagnosed). 

• “Diagnosis: no primary tumor” – this state contains patients without diagnosed 

primary tumor of unknown primary origin neoplasms. If no primary tumor was 


o Patient with primary tumor (in case of incorrect lack of primary tumor 

diagnosis); 

o Patient without primary tumor (if the lack of primary tumor was correctly 

diagnosed). 

The figure below shows the illustration of the decision tree of the model, describing the 

course of primary tumor in unknown primary origin neoplasms detection, using PET-CT and 

computed tomography. 

72



Figure 6. 

Decision tree showing the model used in calculations of PET-CT vs CT comparison, used in the primary tumor 

diagnostics in case of unknown primary origin neoplasms (legend – table 49) 


tests had radical surgical and radiological and palliative treatment, patients with negative 

result had chemo-radiotherapy and palliative treatment. 


In a study concerning the primary tumor of unknown primary origin neoplasms diagnostics, 

the hybrid PET-CT was compared to the computed tomography (CT). Computed 

tomography is and out-patient diagnostic service, co-financed (ASDW), that amounts 42 

points – 37 points are refunded by the National Health Fund and the 5 points are covered by 

a physician referring to the procedure (“Catalogue of the co-financed out-patient diagnostic 

procedures ranges (ASDW)”. Annex No. 1b to the informational materials AOS). Referrer 

covers the cost of performed procedure, according to the negotiated price of the point. The 

National Health Fund covers the cost of the co-financed diagnostic procedure, accordingly 

to the prices of the point, negotiated by: health care provider performing the procedure and 

by the referrer. 




PLN. 






73



Table 44. 




Computed 

tomography 








5.03.00.0000029 

NHF refund 


Referrer’s 

surcharge 


[PLN] 



dispensary 

37 5 8,05 7,54 






Table 45. 


catalogue 









5.10.00.0000042 



[PLN] 

420 10,75 

Test 

cost 

(PLN) 

335,55 


4 515,00 

The average CT examination cost in the primary tumor of unknown primary origin 

neoplasms diagnostics amounts 335.55 PLN, and the PET-CT examination cost – from the 

public payer’s perspective – amounts 4,515.00 PLN. 



Table 46. 




PF 







procedure =No 



[PLN] 

7 148,40 

74





PFH&N 

PFELVH&N 

PF1 











1–5 // 






25 mg/m 2 iv days 1–4 // 1000 mg/m 2 iv days 1- 




13 963,20 

6 376,80 

7 148,40 

3 636,00 


services, used in unknown primary origin neoplasms treatment. 

Table 47. 




procedure 








5.07.01.0000022 5 000 

5.07.01.0000023 8 000 




as cost of operative treatment of unknown primary origin neoplasms. 

Table 48. 

Surgical procedures used in unknown primary origin neoplasms treatment 





75











excision 












preservation 





5.06.00.0000481 7 000 

5.06.00.0000682 5 200 

5.06.00.0000689 4 800 

5.06.00.0000479 7 000 

5.06.00.0000480 8 000 

5.06.00.0000482 5 000 

5.06.00.0000483 6 000 

5.06.00.0000484 4 500 

5.06.00.0000134 2 000 





5.06.00.0000161 3 800 







5.06.00.0000478 5 000 

Table 49. 

List of model parameters with values used in the sensitivity analysis of PET-CT vs CT comparison in the primary tumor 

of unknown primary origin neoplasms diagnostics 


76


[PLN] 


[PLN] 

Cost of palliative therapy (cPaliat2) 

[PLN] 



4 515,00 (1 313,00*) 335,55 (265,50; 414,00) 

7 148,40 (3 098,40; 13 963,20) 

7 148,40 (5 718,72; 8 578,08) 

Cost of chemotherapy (cChem) [PLN] 7 148,40** 

Cost of radiotherapy (cRT) [PLN] 5 000,00 (1 800,00; 8 000,00) 

Cost of radical therapy (cLeczRadyk) 

[PLN] 

Survival in case of lack of tumor or 

resective tumor (eP_LeczRadyk) 

[years] 

Survival in case of non-diagnosed 

tumor – wrong diagnosis 

(eP_GuzUkryty) [years] 


positive result 

5 000,00 (2 000,00; 16 000,00) 

5,0 (4,0; 6,0) 

4,0 (3,0; 5,0) 

0,4872 (0,4071; 0,5672) 0,3590 (0,2822; 0,4358) 

Probability of correct tumor detection 0,9474 (0,9116; 0,9831) 0,6429 (0,5661; 0,7196) 

Probability of correct lack of tumor 

detection 

0,8500 (0,7928; 0,9072) 0,5200 (0,4400; 0,6000) 



** Only chemotherapeutic regimen used in “Unknown primary origin neoplasms – squamous cell carcinoma” 

indication. 






• The average cost of head and neck malignant neoplasms radical treatment was 

assumed as equal to the cost of procedure 5.06.00.0000482 from the catalogue of the 

hospital services (the costs range between minimal and maximal cost of surgical 

procedures used in head and neck malignant tumors treatment – see table 48). 

• As the average cost of palliative treatment (cPaliat) and chemotherapy (cChem), in 

case of no primary tumor, the cost of 6 cycles of PF chemotherapy (form the 

oncologic procedures catalogue) was assumed (the range of costs between minimal 

and maximal cost of surgical procedures, used in head and neck malignant tumors 

treatment – see table 46). 

77



• Cost of the palliative treatment (cPaliat2) was assumed as equal to the cost of 6 

cycles of PF chemotherapy, from the oncologic services catalogue, used in unknown 

primary origin cancers treatment (range +/_ 1 cycle of treatment). 

• The average cost of unknown primary origin cancers involving cervical lymph nodes 

radiotherapy was assumed as the cost of procedure No. 5.07.01.0000022 from the 

oncologic services catalogue – teleradiotherapy, brachytherapy and isotope therapy 

(range of costs between minimal and maximal cost of the procedures used in head 

and neck malignant neoplasms treatment – see table 48). 

• Minimal and maximal lifetime expectancy values in case of detected primary tumor, 

real lack of primary tumor and in case of the primary tumor not detected with 

imaging studies, were assumed on a basis of the literature and estimation of experts 

from the Maria – Curie Skłodowska Memorial Institute Center of Oncology in Warsaw. 





used: 

5.5. RESULTS 

o Freudenberg LS, Fischer M, Antoch G, Jentzen W, Gutzeit A, Rosenbaum 

SJ, Bockisch A, Egelhof T. Dual modality of 18F-fluorodeoxyglucose-positron 

emission tomography/computed tomography in patients with cervical 

carcinoma of unknown primary. Med Princ Pract 2005; Vol. 14 (3): pp 155–160. 

o Gutzeit A, Antoch G, Kuhl H, Egelhof T, Fischer M, Hauth E, Goehde S, Bockisch 

A, Debatin J, Freudenberg L. Unknown primary tumors: detection with dual- 

modality PET-CT--initial experience. Radiology 2005; Vol. 234 (1): pp 227–234. 

Epub 2004 Nov 24. 


computed tomography used in unknown primary origin neoplasms primary tumors detection, 

where the average lifetime expectancy expressed in years, was considered as the effect. 


78



Table 50. 

Results of the cost-effectiveness analysis of the PET-CT vs CT in the unknown primary origin neoplasm primary tumor 

diagnostics 

Procedure 


patient [PLN] 


[PLN] 

Average 

lifetime 

expectancy 

[years] 



3 263,03 

4,692 

Effects 

difference 

(LYG) 

ICER 

[PLN/LYG] 

0,231 14 125,67 

Cost-effectiveness analysis revealed, that diagnostics of primary tumors of unknown primary 

origin neoplasms using PET-CT is more expensive than using computed tomography, but 

simultaneously gives a better long-term effect, measured with life years gained ratio. PET-CT 

cost included costs of the diagnostic procedure, surgical treatment and costs of palliative 

chemotherapy. The cost difference between diagnostic procedures amounts 3,263.03 PLN 

per one patient. Using PET-CT in one patient allows to gain 4.923 life years. In a group of 

patients, where computed tomography is performed, the anticipated effect amounts 4.692 

life years. Difference of effects between PET-CT and CT amounts 0.231 LYG (life years gained) 


Primary tumor of unknown primary origin neoplasms diagnostics, using PET-CT system is more 






79



Table 51. 

Results of the Monte Carlo simulation analysis for 100,000 patients, comparing the PET-CT vs CT in the primary tumor 

diagnostics of unknown primary origin neoplasms 

Parameter 


Cost [PLN] Effect [LYG] Cost [PLN] Effect [LYG] 

ICER 

[PLN/LYG] 

Average 20 336,55 4,925 17 056,99 4,696 14 321,22 



Median 23 811,80 5,000 19 632,35 5,000 

Maximal value 23 811,80 5,000 19 632,35 5,000 




0.229 of a life year. Median of the effect in a group of patient diagnosed using PET-CT 

amounts 5 life years, and in CT group – also 5 life years. Incremental cost-effectiveness ratio 


diagnostics in primary tumor detection in case of unknown primary origin neoplasms, instead 

of CT, costs 14,321.22 PLN. 


One-way sensitivity analysis of the PET-CT vs CT diagnostics in unknown primary origin 

neoplasms primary tumors detection was performed for the different model parameters; 





• minimal and maximal costs of the radical treatment; 

• minimal and maximal costs of the radiotherapy; 


• minimal and maximal costs of the palliative treatment (2); 

• minimal and maximal lifetime expectancy, in case of lack of tumor or in case of 

resective tumor; 

- 

80



• minimal and maximal lifetime expectancy, in case of lack of tumor or in case of 

hidden tumor – wrong diagnosis; 


• maximal and maximal??? probability of the correct primary tumor detection; 

• minimal and maximal probabilities of the correct diagnosis concerning the lack of 

primary tumor. 


Table 52. 

Sensitivity analysis of the PET-CT vs CT in the unknown primary origin neoplasms primary tumor diagnostics 

Parameter 





Alternative PET-CT cost 17 127,10 4,923 17 066,07 4,692 264,20 



Minimal cost of radical 

treatment 

Maximal cost of radical 

treatment 

Minimal cost of 

radiotherapy 

Maximal cost of 

radiotherapy 


palliative 



palliative 



palliative 



palliative 


18 867,50 4,923 15 989,07 4,692 12 460,74 

25 688,30 4,923 21 015,07 4,692 20 230,43 

18 688,14 4,923 15 014,87 4,692 15 901,60 

21 867,50 4,923 18 989,07 4,692 12 460,74 

18 148,20 4,923 14 885,23 4,692 14 125,41 

23 998,82 4,923 20 735,72 4,692 14 125,97 

19 669,29 4,923 16 406,25 4,692 14 125,71 

20 988,91 4,923 17 725,90 4,692 14 125,58 

81

Minimal survival in case 

of lack of tumor or 

resective tumor 

Maximal survival in 

case of lack of tumor or 

resective tumor 

Minimal survival in case 

of hidden tumor – wrong 

diagnosis 

Maximal survival in 

case of hidden tumor – 



PET-CT diagnostic 

procedure positive 

result 


PET-CT diagnostic 


result 


CT diagnostic 


result 


CT diagnostic 


result 


the correct primary 

tumor detection 


the correct primary 

tumor detection 


the correct lack of 

primary tumor detection 


the correct lack of 

primary tumor detection 



20 329,10 4,000 17 066,07 4,000 



20 329,10 5,846 17 066,07 5,385 7 078,16 

20 329,10 4,846 17 066,07 4,385 7 078,16 

20 329,10 5,000 17 066,07 5,000 



20 901,69 4,911 17 066,07 4,692 17 514,25 

19 757,23 4,935 17 066,07 4,692 11 074,73 

20 329,10 4,923 17 615,07 4,655 10 126,98 

20 329,10 4,923 16 517,08 4,729 19 649,59 

20 329,10 4,923 17 066,07 4,692 14 125,67 

20 329,10 4,923 17 066,07 4,692 14 125,67 

20 329,10 4,894 17 066,07 4,641 12 897,35 

20 329,10 4,952 17 066,07 4,744 15 687,64 


the mentioned parameters alterations, characterizing compared diagnostic schemes. 

Diagnostics of primary tumor in unknown primary origin neoplasms using PET-CT remains more 

expensive and more effective than CT diagnostics, only if the minimal survival in case of lack 

of tumor or resective tumor is assumed or in case of the maximal survival of patients with 

hidden tumor (wrong diagnosis) the program was dominated, i.e. PET-CT diagnostics was 

more expensive and equally effective as CT diagnostics. The lowest ICER value was observed 

in case of assumption the alternative cost of PET-CT procedure on the level of 1,313.00 PLN 

(decrease of 98.13% from the baseline value). Maximal ICER ratio value was observed in case 

of assuming the maximal cost of radical treatment (ICER increase of 43.22% from the baseline 

value). 

82




1. Freudenberg LS, Fischer M, Antoch G, Jentzen W, Gutzeit A, Rosenbaum SJ, Bockisch A, Egelhof T. 

Dual modality of 18F-fluorodeoxyglucose-positron emission tomography/computed tomography in 

patients with cervical carcinoma of unknown primary. Med Princ Pract 2005; Vol. 14 (3): pp 155–160. 

2. Gutzeit A, Antoch G, Kuhl H, Egelhof T, Fischer M, Hauth E, Goehde S, Bockisch A, Debatin J, 

Freudenberg L. Unknown primary tumors: detection with dual-modality PET-CT--initial experience. 

Radiology 2005; Vol. 234 (1): pp 227–234. Epub 2004 Nov 24. 



4. Pavlidis N, Briasoulis E, Hainsworth J, et al. Diagnostic and therapeutic management of cancer of an 

unknown primary. Eur J Cancer 2003; 39 (14): pp 1990–2005. 

5. DeSanto LW, Neel HB 3 rd . Squamous cell carcinoma. Metastasis to the neck from an unknown or 

undiscovered primary. Otolaryngol Clin North Am 1985; 18 (3): pp 505–513. 

83



6. OVARIAN CANCER – COST-COMPARISON ANALYSIS – PET-CT 

VS CT 

This indication was initially qualified to the analysis using the ICER ratio, because of the 

statistically significant differences in diagnostic effectiveness parameters of the compared 

imaging techniques (see: “Comparative cost – effect analysis of the positron emission 

tomography PET-CT with diagnostic technologies financed in Poland from the public assets in 

the oncologic diagnostics - epidemiological and clinical part”). Data from the following 

publications were used in the clinical analysis: 

1. Hauth EA, Antoch G, Stattaus J, Kuehl H, Veit P. Evaluation of integrated whole-body 

PET/ CT in detection of recurrent ovarian cancer. Eur J Radiol 2005 Nov; 56 (2): pp 263– 

268. 

2. Makhija S, Howden N, Edwards R, Kelley J, Townsed DW, Meltzer CC. Positron emission 

tomography/computed tomography imaging for the detection of recurrent ovarian 

and fallopian tube carcinoma; a retrospective review. Gynecol Oncol 2002 Apr; 85 

(1): pp 53–58. 

According to the opinion of experts from the Maria Skłodowska-Curie Memorial Institute 

Center of Oncology in Warsaw, due to the lack of change in the prognosis in case of early 

ovarian cancer recurrence after treatment, the analysis with the ICER ratio is not possible to 

perform. Higher diagnostic effectiveness of PET-CT in comparison to CT does not influence the 

clinical effectiveness. Lack of the difference in the clinical effect makes performing analysis, 

utilizing ICER ratio, impossible. 

The cost-comparison analysis was performed and its results are presented below. 


In a study concerning the ovarian cancer diagnostics, the hybrid PET-CT was compared to 

the computed tomography (CT). Computed tomography is and out-patient diagnostic 

service, co-financed (ASDW), that amounts 42 points – 37 points are refunded by the National 

Health Fund and the 5 points are covered by a physician referring to the procedure 

(“Catalogue of the co-financed out-patient diagnostic procedures ranges (ASDW)”. Annex 

No. 1b to the informational materials AOS). Referrer covers the cost of performed procedure, 

according to the negotiated price of the point. The National Health Fund covers the cost of 

the co-financed diagnostic procedure, accordingly to the prices of the point, negotiated by: 

health care provider performing the procedure and by the referrer. 

84






PLN. 






Table 53. 




Computed 

tomography 








5.03.00.0000029 

NHF refund 


Referrer’s 

surcharge 


[PLN] 



dispensary 

37 5 8,05 7,54 






Table 54. 


catalogue 









5.10.00.0000042 



[PLN] 

420 10,75 

Test 

cost 

(PLN) 

335,55 


4 515,00 

The average CT examination cost in the diagnostics of the ovarian cancer amounts 335.55 

PLN, and the PET-CT examination cost – from the public payer’s perspective – amounts 

4,515.00 PLN. 

85

6.2. RESULTS 



The following table contains results of the comparative cost-comparison analysis of PET-CT 

vs computed tomography in the ovarian cancer recurrences detection. 

Table 55. 

Results of the cost-comparison analysis of the PET-CT vs CT in the ovarian cancer recurrence diagnostics 

Procedure Cost per one patient [PLN] Cost difference [PLN] 

PET-CT 4 515,00 

CT 335,55 

4 179,45 

The results of analysis show that ovarian cancer recurrence diagnostics using PET-CT is more 

expensive than computed tomography. 

86



7. OESOPHAGEAL CANCER – COST-COMPARISON ANALYSIS – 

PET-CT VS CT VE EUS-FNA 

This indication was initially qualified to the analysis, because of the statistically significant 

differences in diagnostic effectiveness parameters of the compared imaging techniques 

(see: “Comparative cost – effect analysis of the positron emission tomography PET-CT with 

diagnostic technologies financed in Poland from the public assets in the oncologic 

diagnostics - epidemiological and clinical part”). Data from the following publications were 

used in the clinical analysis: 

1. Cerfolio RJ, Bryant AS, Ohja B, Bartolucci AA, Eloubeidi MA. The accuracy of 

endoscopic ultrasonography with fine-needle aspiration, integrated positron emission 

tomography with computed tomography, and computed tomography in restaging 

patients with esophageal cancer after neoadjuvant chemoradiotherapy. J Thorac 

Cardiovasc Surg 2005; Vol. 129 (6): pp 1232–1241. 

Due to the lack of possibility to utilize data concerning diagnostic effectiveness of 

compared methods in clinical advancement assessment, after neoadiuvant oesophageal 

cancer treatment and before performing surgical procedure, in the analysis with ICER ratio, 

such analysis was not performed. 

Available data concerned effectiveness of diagnostic methods in assessing local 

advancement of the cancer, lymph nodes involvement and metastases detection. Lack of 

the combined clinical information evaluating diagnostic effectiveness of analyzed methods 

in a full TNM scale made classification the analyzed population into groups of particular 

prognosis and treatment regimen impossible. Data concerning diagnostic effectiveness, not 

influencing the clinical effects and costs, cannot be used in constructing a model of analysis 

utilizing ICER ratio. 



In a study concerning the reassessment of the clinical stage of patients with the 

oesophageal cancer, after the neoadiuvant therapy (restaging), the hybrid PET-CT was 

compared to the computed tomography (CT) and with the transoesophageal ultrasound- 

guided fine needle aspiration biopsy (EUS-FNA). 

Computed tomography is an out-patient, co-financed (ASDW) diagnostic service, that 

amounts 42 points – 37 points are refunded by the National Health Fund and the remaining 5 

87



points are covered by a physician referring to the procedure (“Catalogue of the co-financed 

out-patient diagnostic procedures ranges (ASDW)”. Annex No. 1b to the informational 

materials AOS). Referrer covers the cost of performed procedure, according to the 

negotiated price of the point. The National Health Fund covers the cost of the co-financed 

diagnostic procedure, accordingly to the prices of the point, negotiated by: health care 

provider performing the procedure and by the referrer. 

Similarly to the previous chapters, it was assumed that referring center is the oncologic 

dispensary. The average price of the settlement point in the oncologic dispensary, calculated 

on the basis of the point price in all such institutions in Poland, bounded with the NHF contract 

(data in the annex), amounts 7.54 PLN. 

The average point price in the computed tomography laboratory, calculated on the basis 

of the point price in all computed tomography laboratories having the contract with the 

National Health Fund in Poland, amounts 8.05 PLN. 

Transoesophageal ultrasound-guided fine needle aspiration biopsy (EUS-FNA) is a 

diagnostic procedure, not co-financed, amounting 15 points. 

The price of the point for the fine needle biopsy of the focal lesion, using the imaging 

technique with the cytologic examination (2-4 smears; necessary photographic 

documentation of the needle tip in the punctured lesion) in the general surgery ward 

amounts 11.00 PLN. 

The following table shows the characteristics of the CT and EUS-FNA as well as its costs 

calculations. 

Table 56. 

Service characteristics and the computed tomography and transoesophageal ultrasound-guided fine needle aspiration 

biopsy (EUS-FNA) costs calculations 



Computed 

tomography 


EUS-FNA 



CT: One or more parts of 

the body examination - 


5.03.00.0000029 

Fine needle biopsy of 

one focal lesion, using 

the imaging technique 

NHF refund 


Referrer’s 

surcharge 


[PLN] 

NHF refund 

Oncologic 

dispensary 

37 5 8,05 7,54 

Test 

cost 

(PLN) 

335,55 

15 - 11,00 - 165,00 

88



with the cytologic 

examination (2-4 smears; 

necessary photographic 

documentation of the 

needle tip in the 

punctured lesion) 

5.05.00.0000046 


settlement point in positron emission tomography in the Center of Oncology in Bydgoszcz 

amounts 10.75 PLN. 



Table 57. 

Service characteristics and PET-CT cost calculation 









5.10.00.0000042 



[PLN] 

420 10,75 


4 515,00 

In case of oesophageal cancer restaging, the cost of the computed tomography (CT) 

amounts 335.55 PLN, and the estimated cost of the comparative test, i.e. transoesophageal 

ultrasound-guided fine needle aspiration biopsy (EUS-FNA) amounted 165.00 PLN. Cost of the 

PET-CT procedure – from the public payer's perspective – amounts 4,515.00 PLN. 

7.2. RESULTS 


vs computed tomography in the oesophageal cancer clinical advancement assessment, 

after neoadiuvant treatment. 

89



Table 58. 

Results of the cost-comparison analysis of the PET-CT vs CT vs EUS-FNA in the oesophageal cancer clinical 

advancement assessment, after neoadiuvant treatment 

Procedure Cost per one patient [PLN] 


Costs difference (PET-CT – CT and 

PET-CT – EUS-FNA) [PLN] 

CT 335,55 4 179,45 

EUS-FNA 165,00 4 350,00 

The results of analysis show that oesophageal cancer clinical advancement, after 

neoadiuvant treatment assessment using PET-CT is more expensive than computed 

tomography or EUS-FNA. 

90



8. LYMPHOMAS – COST-COMPARISON ANALYSIS – PET-CT VS CT 







1. Freudenberg LS, Antoch G, Schütt P, Beyer T, Jentzen W, Müller SP, Görges R, 

Nowrousian MR, Bockisch A, Debatin JF. FDG-PET-CT in re-staging of patients with 

lymphoma. Eur J Nucl Med Mol Imaging 2004; 31 (3): pp 325–329. 

2. Schaefer NG, Hany TF, Taverna C, Seifert B, Stumpe KD, von Schulthess GK, Goerres 

GW. Non-Hodgkin lymphoma and Hodgkin disease: coregistered FDG PET and CT at 

staging and restaging – do we need contrast-enhanced CT? Radiology 2004 Sep; 232 

(3): pp 823–829. 



lymphomas recurrence after treatment, the analysis with the ICER ratio is not possible to 

perform. Lack of the clinical effects difference makes performing such analysis impossible. 



In a study concerning the lymphomas diagnostics, the hybrid PET-CT was compared to the 

computed tomography (CT). Computed tomography is and out-patient diagnostic service, 

co-financed (ASDW), that amounts 42 points – 37 points are refunded by the National Health 

Fund and the 5 points are covered by a physician referring to the procedure (“Catalogue of 

the co-financed out-patient diagnostic procedures ranges (ASDW)”. Annex No. 1b to the 

informational materials AOS). Referrer covers the cost of performed procedure, according to 

the negotiated price of the point. The National Health Fund covers the cost of the co- 

financed diagnostic procedure, accordingly to the prices of the point, negotiated by: health 

care provider performing the procedure and by the referrer. 



91




PLN. 






Table 59. 




Computed 

tomography 








5.03.00.0000029 

NHF refund 


Referrer’s 

surcharge 


[PLN] 



dispensary 

37 5 8,05 7,54 






Table 60. 


catalogue 









5.10.00.0000042 



[PLN] 

420 10,75 

Test 

cost 

(PLN) 

335,55 


4 515,00 

The average CT examination cost in the diagnostics of the lymphomas amounts 335.55 PLN, 

and the PET-CT examination cost – from the public payer’s perspective – amounts 4,515.00 

PLN. 

92

8.2. RESULTS 




vs computed tomography in the lymphomas recurrences detection. 

Table 61. 

Results of the cost-comparison analysis of the PET-CT vs CT in the lymphomas recurrence diagnostics 




4 179,45 

The results of analysis show that lymphomas recurrence diagnostics using PET-CT is more 


93



9. THYROID CANCER – COST-COMPARISON ANALYSIS – PET-CT 

VS WHOLE-BODY SCINTIGRAPHY 







1. Nahas Z, Goldenberg D, Fakhry C, Ewertz M, Zeiger M, Ladenson PW, Wahl R, Tufano 

RP. The role of positron emission tomography/computed tomography in the 

management of recurrent papillary thyroid carcinoma. Laryngoscope 2005 Feb; 115 

(2): pp 237–243. 

2. Freudenberg LS, Antoch G, Jentzen W, Pink R, Knust J, Gorges R, Muller SP, Bockisch A, 

Debatin JF, Brandau W. Value of 124I -PET-CT in staging of patients with differentiated 

thyroid cancer. Eur Radiol 2004; Vol. 14 (11): pp 2092–2098. 

3. Zimmer LA, McCook B, Meltzer C, Fukui M, Bascom D, Snyderman C, Townsend DW, 

Johnson JT. Combined positron emission tomography/computed tomography 

imaging of recurrent thyroid cancer. Otolaryngology – Head & Neck Surgery 2003; 

Vol. 128 (2): pp 178–184. 



thyroid cancer recurrence after treatment, the analysis with the ICER ratio is not possible to 

perform. In a preliminary assessment of the thyroid cancer clinical advancement, the PET-CT 

method is not indicated. Lack of the difference in the clinical effect makes performing 

analysis, utilizing ICER ratio, impossible. 



In the analysis of the thyroid cancer recurrence diagnostics, on a basis of the clinical report, 

the diagnostic method compared with PET-CT was I 131 whole-body scintigraphy. Scintigraphy 

is an out-patient diagnostic, co-financed (ASDW) procedure, that amounts 30 points – 25 

points are refunded by the National Health Fund and the 5 remaining points are covered by 

a physician referring to the procedure (“Catalogue of the co-financed out-patient diagnostic 

procedures ranges (ASDW)”. Annex No. 1b to the informational materials AOS). Referrer 

covers the cost of performed procedure, according to the negotiated price of the point. The 

94



National Health Fund covers the cost of the co-financed diagnostic procedure, accordingly 

to the prices of the point, negotiated by: health care provider performing the procedure and 

by the referrer. 




PLN. 

Similarly, the average point price of the scintigraphy, calculated on the basis of the point 

price in all dispensaries having the contract with the National Health Fund in Poland, amounts 

8.05 PLN. 

The table below shows the points prices of the I 131 whole-body scintigraphy and the value of 

the settlement point (in PLN). 

Table 62. 

Service characteristics and the whole-body scintigraphy cost calculation, on a basis of the ASDW catalogue 



I 131 whole-body 

scintigraphy 



Whole-body 

scintigraphy (skeletal 

system) 

5.03.00.0000020 

NHF refund 


Referrer’s 

surcharge 


[PLN] 

NHF refund Oncologic 

dispensary 

Test 

cost 

(PLN) 

25 5 8,05 7,54 238,95 

I 131 whole-body scintigraphy in the diagnostics of thyroid cancer amounts 238.95 PLN, and 

the cost of PET-CT amounts 4,515.00 PLN. 






Table 63. 


catalogue 







[PLN] 


95







5.10.00.0000042 

420 10,75 

4 515,00 

The CT examination cost in the diagnostics of the thyroid cancer amounts 335.55 PLN, and 

the PET-CT examination cost – from the public payer’s perspective – amounts 4,515.00 PLN. 

9.2. RESULTS 


vs computed tomography in the thyroid cancer recurrences detection. 

Table 64. 

Results of the cost-comparison analysis of the PET-CT vs I 131 whole-body scintigraphy in the thyroid cancer recurrence 

diagnostics 



I 131 whole-body scintigraphy 238,95 

4 276,05 

The results of analysis show that thyroid cancer recurrence diagnostics using PET-CT is more 

expensive than I 131 whole-body scintigraphy. 

96



10. PANCREATIC CANCER – COST-COMPARISON ANALYSIS – 

PET-CT VS CT 







1. Heinrich S, Goerres GW, Schafer M, Sagmeister M, Bauerfeind P, Pestalozzi BC, Hany TF, 

von Schulthess GK, Clavien P. Positron emission tomography/computed tomography 

influences on the management of resectable pancreatic cancer and its costeffectiveness. 

Ann Surg 2005; Vol. 242 (2): pp 235-243. 

Due to the lack of difference of clinical effects analysis with ICER ratio in case of influence 

of clinical advancement assessment of pancreatic cancer before surgical procedure on 

applied treatment strategy was not performed in the model. 

Available data concerned effectiveness of diagnostic methods in assessing clinical 

advancement of the cancer and its influence on applied treatment. In spite of statistically 

significant differences in parameters describing efficacy of diagnostics performed using 

compared methods, due to the specific results configuration in the model there were not any 

differences in the clinical effect (patients survival). Lack of the difference in the clinical effect 

makes performing analysis, utilizing ICER ratio, impossible. 

Patients qualifying to the radical treatment, that were not treated due to the diagnostic 

error should have shortened life expectancy, accordingly to the opinion of experts from the 

Maria Skłodowska-Curie Memorial Institute Center of Oncology in Warsaw. Because 

accordingly to data from publication (see reference above) none of the compared 

diagnostic methods falsely revealed unresectability of the pancreatic cancer, in case 

reference procedure revealed a possibility of applying surgical treatment, there was not any 

difference of clinical effects between compared methods. 



In a study concerning the pancreatic cancer diagnostics, the hybrid PET-CT was compared 

to the computed tomography (CT). Computed tomography is and out-patient diagnostic 

97



service, co-financed (ASDW), that amounts 42 points – 37 points are refunded by the National 

Health Fund and the 5 points are covered by a physician referring to the procedure 

(“Catalogue of the co-financed out-patient diagnostic procedures ranges (ASDW)”. Annex 

No. 1b to the informational materials AOS). Referrer covers the cost of performed procedure, 

according to the negotiated price of the point. The National Health Fund covers the cost of 

the co-financed diagnostic procedure, accordingly to the prices of the point, negotiated by: 

health care provider performing the procedure and by the referrer. 




PLN. 






Table 65. 




Computed 

tomography 








5.03.00.0000029 

NHF refund 


Referrer’s 

surcharge 


[PLN] 



dispensary 

37 5 8,05 7,54 






Test 

cost 

(PLN) 

335,55 

98



Table 66. 


catalogue 









5.10.00.0000042 



[PLN] 

420 10,75 


4 515,00 

The average CT examination cost in the diagnostics of the pancreatic cancer amounts 

335.55 PLN, and the PET-CT examination cost – from the public payer’s perspective – amounts 

4,515.00 PLN. 

10.2. RESULTS 


vs computed tomography in the pancreatic cancer diagnostics. 

Table 67. 

Results of the cost-comparison analysis of the PET-CT vs CT in the pancreatic cancer diagnostics 




4 179,45 

The results of analysis show that pancreatic cancer diagnostics using PET-CT is more 


99



11. COLON CANCER - NO ANALYSIS - PET-CT VS CT 

This indication was initially qualified to the analysis, because there was no data excluding 

existence of statistically significant difference in diagnostic effectiveness parameters of the 

compared imaging techniques (see: “Comparative cost – effect analysis of the positron 

emission tomography PET-CT with diagnostic technologies financed in Poland from the public 

assets in the oncologic diagnostics - epidemiological and clinical part”). Data from the 

following publications were used in the clinical analysis: 

1. Veit P, Antoch G, Stergar H, Bockisch A, Forsting M, Kuehl H. Detection of residual 

tumor after radiofrequency ablation of liver metastasis with dual-modality PET-CT: 

Initial results. Eur Radiol 2006; Vol. 16 (1): pp 80–87. 

Due to the lack of possibility to utilize, in the analysis with ICER ratio, data concerning 

diagnostic effectiveness of compared methods in the assessment of residual lesions after 

colon cancer liver metastases radio-frequency ablation (in case of contraindications to 

remove the lesions surgically), the analysis with ICER ratio was not performed in this indication. 

Available data concerned the effectiveness of diagnostic methods in the residual disease 

after ablation assessment. Presented results are counted on the quantity of lesions, there are 

no results counted on the quantity of patients. Due to that reason information from the study 

could not be used in the cost-effectiveness analysis model construction and cost comparison 

analysis is also impossible. 

100

12. DISCUSSION 



In some indications PET-CT is more effective and simultaneously more expensive diagnostic 

method than other compared techniques. The diagnostic efficacy differences of compared 

methods lead to differences of clinical efficacy and treatment costs. 

Accurate diagnostics of head and neck malignant neoplasms metastases produces 

savings due to delay of inadequate therapy. Radical treatment (surgical and radiological) of 

patients with distant metastases only multiply costs, do not give better effects. Patients 

without metastases, when good diagnosed, have a chance for radical treatment, 

inaccurate diagnostics cause lost of this chance and impact on survival. Using PET-CT instead 

of CT, for 8,100.09 PLN, one life year will be gained. 

Accurate early diagnostics of head and neck malignant neoplasms recurrences allows 

adequate, improving survival, treatment of patients with recurrence. In case of patients with 

no recurrence performing of accurate diagnostics save money, losing on needless treatment 

when diagnose is inaccurate. Using PET-CT instead of CT, for 33,016.54 PLN, one life year will 

be gained. 

Accurate diagnostics of unknown primary origin of head and neck malignant neoplasms 

increase survival. Inaccurate diagnose reduce chance for radical treatment. Patients without 

primary tumor, when good diagnosed, can avoid needless treatment, inaccurate diagnostics 

cause rise of costs. Using PET-CT instead of CT, for 38,322.77 PLN, one life year will be gained. 

Accurate staging of non-small cell lung cancer increase survival in case of low stage 

patients and reduce costs in case of high stage patients. Inaccurate diagnose reduce 

chance for radical treatment in case of low stage patients and produces cost of inadequate 

surgical treatment in case of high stage patients. Using PET-CT instead of CT, for 152,862.22 

PLN, one life year will be gained. 

In assessment of GIST response to imatinib therapy, accurate diagnose of response increase 

survival. Using PET-CT instead of CT, for 159,626.51 PLN, one life year will be gained. 

Accurate diagnostics of primary tumor of unknown primary origin malignant neoplasms 

increase survival. Inaccurate diagnose reduce chance for radical treatment. Patients without 

primary tumor, when good diagnosed, can avoid needless treatment, inaccurate diagnostics 

cause rise of costs. Using PET-CT instead of CT, for 14,125.67 PLN, one life year will be gained. 

101



For some medical indications primarily included into cost-effectiveness analysis, due to 

insufficient data, were performed only cost comparison analysis. PET-CT is more expensive 

than other diagnostic methods. In one case no analysis was possible. 

Accuracy of diagnostic tests data used in analysis came from “Comparative cost – effect 

analysis of the positron emission tomography PET-CT with diagnostic technologies financed in 

Poland from the public assets in the oncologic diagnostics - epidemiological and clinical 

part”. This situation produces limitations due to search strategy of the report. Only 

randomized controlled trials were included into report, what guarantee high reliability of data 

but also limit quantity of available information. 

Survival data was assumed by experts on basis of literature and their own clinical 

experiences. Generally the problem is assumption of inaccurate diagnostics influence on 

patients’ survival, so due to lack of better sources of data, particularly for polish medical 

circumstances, experts’ estimations were used. 

Sensitivity analysis revealed stability of the performed calculations for the described 

alterations of parameters, characterizing compared diagnostic schemes. Survival data had 

the most critical impact on results. 

102

13. LIST OF TABLES 



Table 1. Service characteristics and the head computed tomography cost calculation, on a 

basis of the ASDW catalogue ................................................................................................10 

Table 2. Service characteristics and PET-CT diagnostics calculation, on the basis of the 

individually contracted services catalogue .......................................................................10 

Table 3. Costs of the selected therapies, from the NHF services catalogue, used in head and 

neck malignant neoplasms treatment.................................................................................10 

Table 4. Costs of the selected radiotherapeutic procedures used in head and neck malignant 

neoplasms treatment, on a basis of the NHF services catalogue ..................................11 

Table 5. Surgical procedures used in head and neck malignant neoplasms metastases 

treatment ...................................................................................................................................11 

Table 6. List of model parameters with values used in the sensitivity analysis of PET-CT vs CT 

comparison in the head and neck malignant neoplasms metastases diagnostics...13 

Table 7. List of cost-effectiveness analysis results of the PET-CT vs CT in the head and neck 

malignant neoplasm metastases diagnostics ....................................................................14 

Table 8. Results of analysis obtained using the Monte Carlo simulation method for 100,000 

patients, comparing PET-CT vs CT in the head and neck malignant neoplasm 

metastases diagnostics ...........................................................................................................15 

Table 9. Sensitivity analysis of the PET-CT vs CT in the head and neck malignant neoplasm 

metastases diagnostics ...........................................................................................................16 

Table 10. Service characteristics and the computed tomography cost calculation, on a basis 

of the ASDW catalogue ..........................................................................................................20 



Table 12. Costs of the selected therapies, from the NHF services catalogue, used in head and 

neck malignant neoplasms treatment.................................................................................21 

Table 13. Costs of selected radiotherapeutic procedures used in head and neck malignant 

neoplasms treatment, on a basis of NHF's catalogue of services. .................................22 

Table 14. Surgical procedures used in head and neck malignant neoplasms treatment .........22 


comparison in the head and neck malignant neoplasms recurrences diagnostics..23 

Table 16. Results of the cost-effectiveness analysis of the PET-CT vs CT in the head and neck 

malignant neoplasm recurrence diagnostics.....................................................................25 

Table 17. Results of the Monte Carlo simulation analysis for 100,000 patients, comparing the 

PET-CT vs CT in the head and neck malignant neoplasm recurrence diagnostics ....26 


recurrences diagnostics ..........................................................................................................27 





Table 21. Costs of the selected therapies from the NHF’s catalogue of services.........................32 

103




Table 23. Surgical procedures used in head and neck malignant neoplasms treatment .........33 


comparison in the primary tumor of head and neck malignant neoplasms 

diagnostics.................................................................................................................................34 

Table 25. Results of the cost-effectiveness analysis of the PET-CT vs CT in the head and neck 

malignant neoplasm primary tumor diagnostics ...............................................................36 


PET-CT vs CT in the head and neck malignant neoplasm primary tumor diagnostics 

......................................................................................................................................................37 


primary tumor diagnostics ......................................................................................................38 





Table 30. Costs of the selected chemotherapy regimens from the NHF’s catalogue of services 

......................................................................................................................................................47 


Table 32. Selected surgical procedures used in lung cancer treatment.......................................48 

Table 33. Comparison of model parameters with values used in the sensitivity analysis of PET- 

CT vs CT comparison in the clinical advancement of non-small cell lung cancer 

diagnostics.................................................................................................................................48 

Table 34. Results of the cost-effectiveness analysis of the PET-CT vs CT in the non-small cell lung 

cancer clinical advancement assessment .........................................................................52 


PET-CT vs CT in the diagnostics of non-small cell lung cancer clinical advancement 

......................................................................................................................................................53 

Table 36. Sensitivity analysis of the comparison PET-CT vs CT in the non-small cell lung cancer 

clinical advancement assessment .......................................................................................55 





Table 39. Active substance used in GIST treatment and its point value on a basis of the 

therapeutic programs catalogue.........................................................................................63 

Table 40. Comparison of model parameters with values used in the sensitivity analysis of PET- 

CT vs CT comparison in the assessment of GIST response to imatinib treatment ........64 

Table 41. List of the cost-effectiveness analysis results concerning comparison of PET-CT vs CT 

in the assessment of the GIST treatment with imatinib response ....................................65 


PET-CT vs CT in the GIST response to imatinib assessment ................................................66 

Table 43. Sensitivity analysis of comparison of PET-CT vs CT in the assessment of GIST response 

to imatinib treatment...............................................................................................................67 

104









Table 48. Surgical procedures used in unknown primary origin neoplasms treatment...............75 


comparison in the primary tumor of unknown primary origin neoplasms diagnostics 

......................................................................................................................................................76 

Table 50. Results of the cost-effectiveness analysis of the PET-CT vs CT in the unknown primary 

origin neoplasm primary tumor diagnostics........................................................................79 


PET-CT vs CT in the primary tumor diagnostics of unknown primary origin neoplasms 

......................................................................................................................................................80 

Table 52. Sensitivity analysis of the PET-CT vs CT in the unknown primary origin neoplasms 

primary tumor diagnostics ......................................................................................................81 





Table 55. Results of the cost-comparison analysis of the PET-CT vs CT in the ovarian cancer 

recurrence diagnostics............................................................................................................86 

Table 56. Service characteristics and the computed tomography and transoesophageal 

ultrasound-guided fine needle aspiration biopsy (EUS-FNA) costs calculations..........88 

Table 57. Service characteristics and PET-CT cost calculation.........................................................89 

Table 58. Results of the cost-comparison analysis of the PET-CT vs CT vs EUS-FNA in the 

oesophageal cancer clinical advancement assessment, after neoadiuvant 

treatment ...................................................................................................................................90 





Table 61. Results of the cost-comparison analysis of the PET-CT vs CT in the lymphomas 

recurrence diagnostics............................................................................................................93 

Table 62. Service characteristics and the whole-body scintigraphy cost calculation, on a basis 




Table 64. Results of the cost-comparison analysis of the PET-CT vs I131 whole-body 

scintigraphy in the thyroid cancer recurrence diagnostics.............................................96 





105



Table 67. Results of the cost-comparison analysis of the PET-CT vs CT in the pancreatic cancer 

diagnostics.................................................................................................................................99 

106

14. LIST OF FIGURES 



Figure 1. Decision tree showing the model used in the calculations of PET-CT vs CT 

comparison, used in the diagnostics of the head and neck malignant neoplasms 

(legend – table 6).......................................................................................................................9 

Figure 2. Decision tree presenting model used in calculations of PET-CT vs CT comparison, in 

the head and neck malignant neoplasms recurrences detection (legend - table 15) 

......................................................................................................................................................19 

Figure 3. Decision tree showing the model used in calculations of PET-CT vs CT comparison, 

used in the diagnostics of the head and neck malignant neoplasms primary tumor 

(legend – table 24)...................................................................................................................30 


comparison, used in the non-small cell lung cancer clinical advancement 

assessment 

(legend – table 33)...................................................................................................................45 


comparison, used to assess the response for imatinib treatment of GIST (legend – 

table 40) .....................................................................................................................................62 

Figure 6. Decision tree showing the model used in calculations of PET-CT vs CT comparison, 

used in the primary tumor diagnostics in case of unknown primary origin neoplasms 

(legend – table 49)...................................................................................................................73 

107

Cost-effect analysis of the PET-CT system. Analysis in the clinical ...

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