1308 AJR:191, November 2008 tive stage I–II breast cancer without palpable adenopathy [7]. In centers of expertise, SLN biopsy, because of its minimally invasive na- ture, has emerged as the standard of care for axillary staging in this population [2–6]. Even so, SLN biopsy has the disadvantages of a false-negative rate of 8–9% [4, 8]; risk of complications such as seroma, neuropathy, and lymphedema; and high cost driven by intraoperative and postoperative histologic findings [9, 10]. MR lymphangiography is a high-resolu- tion imaging technique in which differentia- tion of benign and malignant lymph nodes is based on differential uptake of lymphotropic nanoparticles [11–16]. Compared with SLN Staging MR Lymphangiography of the Axilla for Early Breast Cancer: Cost-Effectiveness Analysis Pari V. Pandharipande 1,2 Mukesh G. Harisinghani 2 Elissa M. Ozanne 1 Michelle C. Specht 3 Chin Hur 4 Janie M. Lee 1 G. Scott Gazelle 1 Pandharipande PV, Harisinghani MG, Ozanne EM, et al. 1 Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac St., 10th Fl., Boston, MA 02114. Address correspondence to P. V. Pandharipande. 2 Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Boston, MA. 3 Surgical Oncology, Massachusetts General Hospital, Boston, MA. 4 Gastrointestinal Unit, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA. Women’s฀Imaging฀•฀Original฀Research AJR 2008; 191:1308–1319 0361–803X/08/1915–1308 © American Roentgen Ray Society I nvasive breast cancer accounted for an estimated 178,480 new cancer diagnoses and 40,460 cancer deaths in the United States in 2007 [1]. Because of the favorable prognosis of early-stage breast cancer, ef- forts to minimize adverse diagnostic and treatment effects are warranted. The devel- opment of less aggressive management op- tions, such as breast conservation surgery and sentinel lymph node (SLN) biopsy, has resulted in substantial paradigm shifts to- ward less invasive treatment [2–6]. Axillary node status can be a critical de- terminant of treatment recommendations and survival among patients with preopera- Keywords: breast cancer, cost-effectiveness analysis, MR lymphangiography, sentinel lymph node biopsy DOI:10.2214/AJR.07.3861 Received February 18, 2008; accepted after revision June 2, 2008. Supported by National Institutes of Health (NIH) R25 CA 92203 training grant (Program for Cancer Outcomes Research Training, G. S. Gazelle, principal investigator; P. V. Pandharipande, trainee, 2004–2006). WOMEN’S IMAGING OBJECTIVE. The purpose of this study was to compare the cost-effectiveness of MR lymphangiography–based strategies with that of sentinel lymph node (SLN) biopsy alone in the axillary staging of early breast cancer. MATERIALS฀AND฀METHODS. A decision-analytic Markov Model was developed to estimate quality-adjusted life expectancy and lifetime costs among 61-year-old women with clinically node-negative early breast cancer. Three axillary staging strategies were compared: MR lymphangiography alone, combined MR lymphangiography–SLN biopsy, and SLN biopsy alone. The model incorporated treatment decisions, outcome, and costs consequent to axillary staging results. An incremental cost-effectiveness analysis was performed to compare strate- gies. The effect of changes in key parameters on results was addressed in sensitivity analysis. RESULTS. In the base-case analysis, combined MR lymphangiography–SLN biopsy was associated with the highest quality-adjusted life expectancy (13.970 years) and cost ($63,582), followed by SLN biopsy alone (13.958 years, $62,462) and MR lymphangiography alone (13.957 years, $61,605). MR lymphangiography–SLN biopsy and SLN biopsy both were as- sociated with higher life expectancy and cost relative to those of MR lymphangiography. MR lymphangiography–SLN biopsy, however, was associated with greater overall life expectancy and greater added life expectancy per dollar than was SLN biopsy. SLN biopsy alone there- fore was not considered cost-effective, but MR lymphangiography and MR lymphangiogra- phy–SLN biopsy remained competing choices. Preference of MR lymphangiography strate- gies was most dependent on the sensitivity of MR lymphangiography and SLN biopsy and on the quality-of-life consequences of SLN biopsy and axillary lymph node dissection, but oth- erwise was stable across most parameter ranges tested. CONCLUSION. From a cost-effectiveness perspective, MR lymphangiography strate- gies for axillary staging of early breast cancer are preferred over SLN biopsy alone. The sensitivity of MR lymphangiography is a critical determinant of the cost-effectiveness of MR lymphangiography strategies and merits further investigation in the care of patients with early breast cancer. Pandharipande et al. Cost-Effectiveness of MR Lymphangiography for Breast Cancer Women’s Imaging Original Research Downloaded from www.ajronline.org by 52.73.204.196 on 05/16/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved