|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 24, No 25 (September 1), 2006: pp. 4116-4122 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.07.0409 Cost-Effectiveness Analysis of Computerized Tomography in the Routine Follow-Up of Patients After Primary Treatment for Hodgkin’s Disease
From the Joint Center for Radiation Therapy/Harvard Radiation Oncology Program; Department of Health Policy and Management, Harvard School of Public Health, Harvard University; and the Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women’s Hospital Boston, MA Address reprint requests to Beverly A. Guadagnolo, MD, MPH, Department of Radiation Oncology, Harvard University, 375 Longwood Ave, Boston, MA 02215; e-mail: aguadagnolo{at}post.harvard.edu
Purpose: To estimate the clinical benefits and cost effectiveness of computed tomography (CT) in the follow-up of patients with complete response (CR) after treatment for Hodgkin’s disease (HD). Patients and Methods: We developed a decision-analytic model to evaluate follow-up strategies for two hypothetical cohorts of 25-year-old patients with stage I-II or stage III-IV HD, treated with doxorubicin, bleomycin, vinblastine, and dacarbazine-based chemotherapy with or without radiation therapy, respectively. We compared three strategies for observing asymptomatic patients after CR: routine annual CT for 10 years, annual CT for 5 years, or follow-up with non-CT modalities only. We used Markov models to calculate life expectancy, quality-adjusted life expectancy, and lifetime costs. Baseline probabilities, transition probabilities, and utilities were derived from published studies. Cost data were derived from the Medicare fee schedule and medical literature. We performed sensitivity analyses by varying baseline estimates. Results: Annual CT follow-up is associated with minimal survival benefit. With adjustments for quality of life, we found a decrement in quality-adjusted life expectancy for early-stage patients followed with CT compared with non-CT modalities. Sensitivity analyses showed annual CT for 5 years becomes more effective than non-CT follow-up if the specificity of CT is 80% or more or if the disutility associated with a false-positive CT result is less than 0.01 quality-adjusted life years (QALYs). For advanced-stage patients, annual CT for 5 years is associated with a very small quality-adjusted survival gain over non-CT follow-up with an incremental cost-effectiveness ratio of $9,042,300/QALY. Conclusion: Our analysis suggests that routine CT should not be used in the surveillance of asymptomatic patients in CR after treatment for HD.
After primary treatment for Hodgkin’s disease (HD), 10% to 15% of patients with early-stage disease will experience relapse, and 35% to 40% of patients with advanced stage at diagnosis will relapse.1,2 Approximately 50% to 60% of patients who relapse may be successfully treated with high-dose chemotherapy and stem-cell transplantation.3,4 Close follow-up allows for relapses to be detected early so that patients can receive salvage therapy while they have a minimal burden of recurrent disease. However, intensive follow-up of these patients also introduces considerable expense as well as the possibility of false-positive test results. The optimal radiological modality and the optimal frequency and duration of its use in the follow-up of patients with HD are not known. Two studies of patients observed in the pre-computed tomography (CT) era have demonstrated that the majority of relapses were detected by history and physical examination.5,6 Investigators at the University of Toronto (Toronto, Canada) reviewed their experience in the follow-up of HD patients in the CT-era. They found that only 9% of HD relapses were detected by routine CT, while almost one third of the total cost of routine follow-up was attributable to routine CT.7 We developed a decision-analytic model to estimate the clinical benefits and optimal duration of CT in the routine follow-up of asymptomatic patients with complete response after primary treatment for HD. We also evaluated the cost effectiveness of routine CT in this setting.
Model Structure We developed a Markov decision-analytic model to evaluate strategies for follow-up of asymptomatic patients who have had a complete response (CR) to primary treatment for HD. We evaluated two hypothetical cohorts of 25-year-old patients, one with stage I-II HD and the other with stage III-IV HD, treated with doxorubicin, bleomycin, vinblastine, and dacarbazine-based chemotherapy with or without radiation therapy, respectively. For each hypothetical cohort (stage I-II and stage III-IV), a Markov state-transition model was used to project life expectancy and quality-adjusted life expectancy.8 Each model consisted of various health states including: no evidence of disease, early-stage relapse, advanced-stage relapse, high-dose chemotherapy (HDCT) with autologous bone marrow transplant (ABMT) salvage, no evidence o disease after salvage, refractory disease, and death. The annual probabilities of transition from one state to another were dependent on clinical stage at initial treatment, relapse stage, and time interval since initial treatment. In each cycle (one year), depending on their health states, patients were at risk of dying from HD, secondary malignancies, cardiac causes, or natural causes. The model was run until all patients died. The Markov model accounts for total costs incurred as patients transition through the different health states and events over their life spans. The three strategies evaluated for follow-up of asymptomatic patients after CR were: annual CT for 10 years, annual CT for 5 years, or non-CT modalities only. Non-CT modalities included history and physical, routine blood work, and chest x-ray. The CT-based strategies also included history and physical and routine blood work, but no chest x-ray. Routine CT examination included chest, abdomen, and pelvis. The incremental cost-effectiveness ratio (ICER) of each strategy was calculated by dividing the incremental cost by the incremental effectiveness, measured in life years and in quality-adjusted life years. Each incremental value represents a comparison with the next least expensive strategy that was not dominated by another comparison. A strategy was considered dominated in the standard sense if an alternative strategy resulted in better overall effectiveness for less overall cost. The analysis was performed from a modified societal perspective, and future costs and benefits were discounted at a rate of 3% annually, as recommended by the US Public Health Service Panel on Cost Effectiveness in Health and Medicine.9 Sensitivity analyses were performed on all probabilities, utility values, and cost estimates. The TreeAgePro Suite software package (TreeAge Software Inc, Williamstown, MA) was used to perform analyses.
Baseline Model and Estimates
Assumptions for transition probabilities. In the baseline model, we assumed that relapses missed by non-CT modalities were detected by CT in 80% of cases, based on sensitivity data for CT in HD patients.13-15 We also assumed that patients with undetected early-stage relapse had a 50% probability of transforming to advanced-stage relapse in 1 year. The baseline model assumption for both cohorts was that 55% of patients with early stage and 45% with advanced-stage disease would relapse. We assumed that 100% of patients relapsing with advanced-stage disease would go on to HDCT. For patients with early-stage relapse, we estimated that 90% would go directly to HDCT and ABMT, while 10% would be eligible for a trial of conventional dose salvage therapy with second-line HDCT for failure. Costs. Costs were derived from the 2005 Medicare fee schedule and medical literature and converted to 2005 US dollars (Table 3). Costs per year included the cost of an office visit and blood tests four times per year for the first 5 years, then annually thereafter for all three strategies. Costs assigned to a false-positive CT scan included cost of CT-guided needle biopsy, preprocedure labs, and pathology processing. While not everyone who has a false-positive CT scan will undergo biopsy, most will undergo additional imaging and increased surveillance to a cost equivalent if not more than the $803 assigned for a CT-guided biopsy.
Costs of relapse were based on treatment received, either HDCT with ABMT as estimated by Vallenga et al,27 or conventional salvage assuming no complications. Simnet et al28 reported that conventional chemotherapy salvage costs were one quarter of the cost of HDCT with ABMT. The costs associated with refractory disease were estimated from published data on cost of care in the last year of life for cancer patients.29 Biasing the model. We structured the model such that it would be biased in favor of the CT follow-up strategies. In the CT-based follow-up strategy arms, patients benefited from the sensitivity of history, physical, and routine labs as well as that of the CT scan when passing through the screening portion of the model, thus increasing the chance of detecting a relapse. Also, it was assumed that in the case of a false-positive CT result and biopsy, no patient would experience complications from the biopsy procedure. In our baseline model, we used the value of 10% probability of death from HDCT with ABMT as cited in the literature. The peritransplant mortality in the current era is likely considerably lower. Our baseline estimate of transplant-related death biased the model in favor of CT follow-up, as slightly fewer patients in the CT follow-up arm would end up receiving HDCT for relapse due to added sensitivity of CT.
Baseline Cost-Effectiveness Analysis of CT Follow-Up Results of the baseline cost-effectiveness analyses are summarized in Table 4. The use of annual CT scans routinely for asymptomatic patients for 5 years increased the mean cost of following patients with early-stage HD from $14,000 to $19,000. The incremental cost of $5,000 represents the excess cost associated with the use of CT scans for routine follow-up for 5 years, including costs associated with a false-positive test result. This strategy was associated with a 0.01 year gain in life expectancy, and with quality-of-life adjustment, there was a decrement in effectiveness of 0.02 quality-adjusted life years. The ICER was $291,500/year, but with quality-of-life adjustment, this strategy was dominated, meaning that the non-CT follow-up strategy resulted in better quality-adjusted life expectancy at less overall cost. When follow-up included annual CT for 10 years, the mean cost of management increased to $24,000 from $14,000 for non-CT follow-up. This strategy was associated with a discounted 0.0002 gain in life expectancy, but a 0.05 decrement in quality-adjusted life expectancy. The ICER for routine CT for 10 year was $14,447,300/year, and with quality-of-life adjustment, the strategy of annual CT scans for 10 years was dominated (reduced quality-adjusted life expectancy at an increased cost).
For patients with advanced-stage disease, the use of annual CT for 5 years increased the mean cost from $23,000 to $27,800. This was associated with a discounted gain in life expectancy of 0.03 years and quality-adjusted life expectancy gain of 0.0005 years. The ICERs were $149,900/year and $9,042,300/quality-adjusted life year. However, when routine CT was used for 10 years, the ICER was $9,507,000/year in the nonquality-adjusted analysis. With quality adjustments, this increased cost was associated with a decrease in quality of life of 0.02 quality-adjusted life years. This strategy was therefore dominated compared with CT follow-up for 5 years with adjustment for quality of life.
Sensitivity Analyses
We also varied the estimate for the sensitivity of non-CT based follow-up in detecting relapses. When it was set at 0% (ie, history and physical examination, blood work, and chest radiograph never pick up relapses) for early-stage patients, the strategy of annual CT follow-up of 5 years became favored. However, even with this extreme assumption, annual CT follow-up for 5 years was still associated with a high ICER of $147,000/quality-adjusted life year, and annual CT follow-up for 10 years remained dominated. For advanced-stage patients, with the assumption of non-CT follow-up never detecting recurrences, annual CT follow-up for 5 years was associated with a much-improved ICER of $35,000/quality-adjusted life year, but annual CT follow-up for 10 years remained dominated. When the specificity of CT was varied from 0% to 100%, for patients with early-stage HD, sensitivity analysis showed that annual CT for 5 years became more effective than non-CT follow-up if the specificity of CT was 84% or higher. When CT specificity was increased to 100%, the ICER for annual CT for 5 years changed from being dominated (baseline model) to $275,000/quality-adjusted life year. The strategy of CT for 10 years remained dominated for all values for specificity of CT. For the analysis for patients with advanced-stage HD, the specificity of CT only needed to go below the baseline estimate of 60% for the non-CT follow-up strategy to become favored over the 5-year CT follow-up strategy. The model was also sensitive to the one time decrement in quality of life associated with a false-positive CT result. For the early-stage analysis, when the disutility was decreased to 0 (no decrement in quality of life), the strategy of annual CT for 5 years was no longer dominated, although this strategy was associated with a rather high ICER of $374,000/quality-adjusted life year. For the advanced-stage cohort, when the quality-of-life decrement associated with a false-positive CT was higher than 0.02, the non-CT follow-up strategy became favored. When the assumption was made that there was no decrement in quality of life for a false-positive CT result, the ICER of CT follow-up for 5 years improved considerably to $147,000/quality-adjusted life year. The strategy of CT follow-up for 10 years was no longer dominated when there was no quality-of-life decrement associated with a false-positive CT, but at a high ICER of over $48,000,000/quality-adjusted life year. The two parameters for which there were no data to guide the baseline estimates, proportion of early-stage relapse and probability of transformation from an early- to an advanced-stage relapse if a relapse went undetected within 1 year of follow-up, were varied from 0% to 100% for both cohorts. For the early-stage model, varying both of these estimated separately and then together in a two-way sensitivity analysis did not change the results of the model in that the CT-based follow-up strategies remained dominated for all values of these parameters. For the advanced-stage patients, if the proportion of early-stage relapse was set below the baseline estimate of 55%, the non-CT follow-up strategy became favored over CT follow-up for 5 years. When 100% of relapses were detected at an early-stage, the ICER improved to $178,000/quality-adjusted life year for CT follow-up for 5 years. When the probability of transformation from early- to advanced-stage relapse decreased from the baseline of 50% to 46%, the non-CT follow-up strategy became favored among the advanced-stage patients. Conversely, when this estimate was increased from 50% to 100%, the ICER of CT for 5 years, while improved, remained high at over $670,000/quality-adjusted life year. The strategy of CT for 10 years remained dominated even when the probability of transformation from early- to advanced-stage relapse if undetected was set at 100%. Sensitivity analyses on all other variables, including costs and other utility estimates did not affect the results of the models. A separate sensitivity analysis including alterations to the model to add a gain in quality of life from having a true-negative CT result was performed to assess the impact of patient preference for more extensive testing. This showed that for all scenarios where the potential utility gain from a true-negative CT result was less than the potential decrement in quality of life for a false-positive result, CT follow-up was dominated.
Using our baseline model, we found that routine CT follow-up of asymptomatic patients in CR after primary treatment for HD was associated with an increased cost and reduced quality-adjusted life expectancy in early-stage patients, and in advanced-stage patients, it had a cost-effectiveness ratio that was well above commonly cited thresholds for the cost effectiveness of medical interventions. The results were robust and remained unaffected by varying most of the estimates over wide ranges in the model. This was despite several structural assumptions placed in the model, which aimed to bias the analysis in favor of CT-based follow-up. Our findings are consistent with other studies that have analyzed surveillance modalities for HD patients after primary treatment, in that testing has not yielded superior outcomes in asymptomatic patients. Radford et al5 showed that 92% of relapses were detected by history, physical, and/or chest radiograph. Investigators at Stanford University (Palo Alto, CA) reported that relapse was detected by history in 55% of patients, physical examination in 14%, chest radiograph in 23%, and abdominal radiograph in 7%.6 Furthermore, they showed that survival was not affected by method of relapse detection. They also showed that cost per relapse detected rose considerably with use of radiographs compared with those detected by history and physical. In the CT era, investigators at the University of Toronto analyzed follow-up practices and costs for patients with HD.7 They reported that while only 9% of relapses were detected by routine CT, 29% of the total cost of follow-up was attributable to routine CT. Our model does not address the role of positron emission tomography (PET) nor PET-CT in the follow-up of patients with HD. Although there have been increasing data on the use of PET in the management of patients with lymphoma, the majority of the data are on its use for initial staging30-40 and prediction of outcome based on midchemotherapy or immediately post-treatment results.41-45 A report by Jerusalem et al46 is the only available study addressing the role of PET in detecting relapses after a CR to first-line HD therapy. Because of the small number of patients and events, it was not possible to reliably determine the sensitivity, specificity, positive predictive value, and negative predictive value of PET in detecting relapses. The inclusion of PET in our model as part of a follow-up strategy was therefore not feasible due to lack of information on these important parameters. Furthermore, while PET and PET-CT are increasingly used in the follow-up of patients with HD, they are not readily available for all practices. Our study is the first to quantify the cost effectiveness of routine CT follow-up of asymptomatic patients after a CR to HD therapy. The results showed that routine CT in addition to other modalities resulted in minimal survival gain for asymptomatic patients in CR after primary treatment for HD. When quality of life adjustments were made in the model, the use of CT scan resulted in a decrease in quality-adjusted survival when used for early-stage patients for 5 years or 10 years, and for advanced-stage patients when used for 10 years. Currently, practice guidelines exist regarding recommendation on use of routine CT in the follow-up of patients treated for Hodgkin’s disease. The National Comprehensive Cancer Network recommended CT follow-up 2 times to 4 times per year for the first 2 years to 3 years and then annually up to 5 years.47 However, this recommendation was classified as category 2b (inconclusive evidence and nonuniform consensus). The American College of Radiology Appropriateness Criteria recommended CT follow-up 1 time to 2 times per year and then annually up to 5 years.48 This recommendation was given an appropriateness score of 8 (9 being most appropriate and 1 being least appropriate). Our analyses, however, suggest that the use of CT as part of follow-up of asymptomatic patients treated for HD is unsupported by available data. Use of CT in follow-up of HD patients should be limited to investigation of symptoms or signs and avoided as a routine surveillance modality.
The authors indicated no potential conflicts of interest.
Supported by National Institutes of Health training Grant No. 5 R25 CA57711-11. Presented in part at the 47th Annual Meeting of the American Society for Therapeutic Radiology and Oncology, Denver, CO, October 16-20, 2005. Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.
1. Oza AM, Ganesan TS, Leahy M, et al: Patterns of survival in patients with Hodgkin’s disease: Long follow up in a single centre. Ann Oncol 4:385-392, 1993 2. Hasenclever D, Diehl V: A prognostic score for advanced Hodgkin’s disease: International Prognostic Factors Project on advanced Hodgkin’s disease. N Engl J Med 339:1506-1514, 1998 3. Linch DC, Winfield D, Goldstone AH, et al: Dose intensification with autologous bone-marrow transplantation in relapsed and resistant Hodgkin’s disease: Results of a BNLI randomised trial. Lancet 341:1051-1054, 1993[CrossRef][Medline] 4. Josting A, Raemakers JM, Diehl V, et al: New concepts for relapsed Hodgkin’s disease. Ann Oncol 13 Suppl 1117-121, 2002[Medline] 5. Radford JA, Eardley A, Woodman C, et al: Follow up policy after treatment for Hodgkin’s disease: Too many clinic visits and routine tests? A review of hospital records. BMJ 314:343-346, 1997 6. Torrey MJ, Poen JC, Hoppe RT: Detection of relapse in early-stage Hodgkin’s disease: Role of routine follow-up studies. J Clin Oncol 15:1123-1130, 1997 7. Dryver ET, Jernstrom H, Tompkins K, et al: Follow-up of patients with Hodgkin’s disease following curative treatment: The routine CT scan is of little value. Br J Cancer 89:482-486, 2003[CrossRef][Medline] 8. Sonnenberg FA, Beck JR: Markov models in medical decision making: A practical guide. Med Decis Making 13:322-338, 1993 9. Weinstein MC, Siegel JE, Gold MR, et al: Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 276:1253-1258, 1996[Abstract] 10. Bonadonna G, Bonfante V, Viviani S, et al: ABVD plus subtotal nodal versus involved-field radiotherapy in early-stage Hodgkin’s disease: Long-term results. J Clin Oncol 22:2835-2841, 2004 11. Canellos GP, Anderson JR, Propert KJ, et al: Chemotherapy of advanced Hodgkin’s disease with MOPP, ABVD, or MOPP alternating with ABVD. N Engl J Med 327:1478-1484, 1992[Abstract] 12. Canellos GP, Niedzwiecki D: Long-term follow-up of Hodgkin’s disease trial. N Engl J Med 346:1417-1418, 2002 13. Dittmann H, Sokler M, Kollmannsberger C, et al: Comparison of 18FDG-PET with CT scans in the evaluation of patients with residual and recurrent Hodgkin’s lymphoma. Oncol Rep 8:1393-1399, 2001[Medline] 14. Jerusalem G, Beguin Y, Fassotte MF, et al: Whole-body positron emission tomography using 18F-fluorodeoxyglucose for posttreatment evaluation in Hodgkin’s disease and non-Hodgkin’s lymphoma has higher diagnostic and prognostic value than classical computed tomography scan imaging. Blood 94:429-433, 1999 15. Schaefer NG, Hany TF, Taverna C, et al: Non-Hodgkin lymphoma and Hodgkin disease: Coregistered FDG PET and CT at staging and restaging–do we need contrast-enhanced CT? Radiology 232:823-829, 2004 16. Yuen AR, Rosenberg SA, Hoppe RT, et al: Comparison between conventional salvage therapy and high-dose therapy with autografting for recurrent or refractory Hodgkin’s disease. Blood 89:814-822, 1997 17. Poen JC, Hoppe RT, Horning SJ: High-dose therapy and autologous bone marrow transplantation for relapsed/refractory Hodgkin’s disease: The impact of involved field radiotherapy on patterns of failure and survival. Int J Radiat Oncol Biol Phys 36:3-12, 1996[CrossRef][Medline] 18. Sureda A, Constans M, Iriondo A, et al: Prognostic factors affecting long-term outcome after stem cell transplantation in Hodgkin’s lymphoma autografted after a first relapse. Ann Oncol 16:625-633, 2005 19. Ferme C, Bastion Y, Lepage E, et al: The MINE regimen as intensive salvage chemotherapy for relapsed and refractory Hodgkin’s disease. Ann Oncol 6:543-549, 1995 20. Anselmo AP, Meloni G, Cavalieri E, et al: Conventional salvage chemotherapy vs. high-dose therapy with autografting for recurrent or refractory Hodgkin’s disease patients. Ann Hematol 79:79-82, 2000[CrossRef][Medline] 21. Brusamolino E, Orlandi E, Canevari A, et al: Results of CAV regimen (CCNU, melphalan, and VP-16) as third-line salvage therapy for Hodgkin’s disease. Ann Oncol 5:427-432, 1994 22. Shamash J, Lee SM, Radford JA, et al: Patterns of relapse and subsequent management following high-dose chemotherapy with autologous haematopoietic support in relapsed or refractory Hodgkin’s lymphoma: A two centre study. Ann Oncol 11:715-719, 2000 23. Sureda A, Arranz R, Iriondo A, et al: Autologous stem-cell transplantation for Hodgkin’s disease: Results and prognostic factors in 494 patients from the Grupo Espanol de Linfomas/Transplante Autologo de Medula Osea Spanish Cooperative Group. J Clin Oncol 19:1395-1404, 2001 24. Ng AK, Weeks JC, Mauch PM, et al: Laparotomy versus no laparotomy in the management of early-stage, favorable-prognosis Hodgkin’s disease: A decision analysis. J Clin Oncol 17:241-252, 1999 25. Ng AK, Weeks JC, Mauch PM, et al: Decision analysis on alternative treatment strategies for favorable-prognosis, early-stage Hodgkin’s disease. J Clin Oncol 17:3577-3585, 1999 26. Ng AK, Kuntz KM, Mauch PM, et al: Costs and effectiveness of staging and treatment options in early-stage Hodgkin’s disease. Int J Radiat Oncol Biol Phys 50:979-989, 2001[CrossRef][Medline] 27. Vellenga E, van Agthoven M, Croockewit AJ, et al: Autologous peripheral blood stem cell transplantation in patients with relapsed lymphoma results in accelerated haematopoietic reconstitution, improved quality of life and cost reduction compared with bone marrow transplantation: The Hovon 22 study. Br J Haematol 114:319-326, 2001[CrossRef][Medline] 28. Simnett SJ, Stewart LA, Sweetenham J, et al: Autologous stem cell transplantation for malignancy: A systematic review of the literature. Clin Lab Haematol 22:61-72, 2000[CrossRef][Medline] 29. Campbell DE, Lynn J, Louis TA, et al: Medicare program expenditures associated with hospice use. Ann Intern Med 140:269-277, 2004 30. Hutchings M, Eigtved AI, Specht L: FDG-PET in the clinical management of Hodgkin lymphoma. Crit Rev Oncol Hematol 52:19-32, 2004[Medline] 31. Schiepers C, Filmont JE, Czernin J: PET for staging of Hodgkin’s disease and non-Hodgkin’s lymphoma. Eur J Nucl Med Mol Imaging 30:S82-S88, 2003 (suppl 1)[Medline] 32. Bangerter M, Moog F, Buchmann I, et al: Whole-body 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) for accurate staging of Hodgkin’s disease. Ann Oncol 9:1117-1122, 1998 33. Partridge S, Timothy A, O’Doherty MJ, et al: 2-Fluorine-18-fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkin’s disease: Influence on patient management in a single institution. Ann Oncol 11:1273-1279, 2000 34. Hueltenschmidt B, Sautter-Bihl ML, Lang O, et al: Whole body positron emission tomography in the treatment of Hodgkin disease. Cancer 91:302-310, 2001[CrossRef][Medline] 35. Jerusalem G, Beguin Y, Fassotte MF, et al: Whole-body positron emission tomography using 18F-fluorodeoxyglucose compared to standard procedures for staging patients with Hodgkin’s disease. Haematologica 86:266-273, 2001 36. Weihrauch MR, Re D, Bischoff S, et al: Whole-body positron emission tomography using 18F-fluorodeoxyglucose for initial staging of patients with Hodgkin’s disease. Ann Hematol 81:20-25, 2002[CrossRef][Medline] 37. Menzel C, Dobert N, Mitrou P, et al: Positron emission tomography for the staging of Hodgkin’s lymphoma: Increasing the body of evidence in favor of the method. Acta Oncol 41:430-436, 2002[CrossRef][Medline] 38. Naumann R, Beuthien-Baumann B, Reiss A, et al: Substantial impact of FDG PET imaging on the therapy decision in patients with early-stage Hodgkin’s lymphoma. Br J Cancer 90:620-625, 2004[CrossRef][Medline] 39. Isasi CR, Lu P, Blaufox MD: A metaanalysis of 18F-2-deoxy-2-fluoro-D-glucose positron emission tomography in the staging and restaging of patients with lymphoma. Cancer 104:1066-1074, 2005[CrossRef][Medline] 40. Hicks RJ, Mac Manus MP, Seymour JF: Initial staging of lymphoma with positron emission tomography and computed tomography. Semin Nucl Med 35:165-175, 2005[CrossRef][Medline] 41. de Wit M, Bohuslavizki KH, Buchert R, et al: 18FDG-PET following treatment as valid predictor for disease-free survival in Hodgkin’s lymphoma. Ann Oncol 12:29-37, 2001 42. Naumann R, Vaic A, Beuthien-Baumann B, et al: Prognostic value of positron emission tomography in the evaluation of post-treatment residual mass in patients with Hodgkin’s disease and non-Hodgkin’s lymphoma. Br J Haematol 115:793-800, 2001[CrossRef][Medline] 43. Spaepen K, Stroobants S, Dupont P, et al: Can positron emission tomography with [(18)F]-fluorodeoxyglucose after first-line treatment distinguish Hodgkin’s disease patients who need additional therapy from others in whom additional therapy would mean avoidable toxicity? Br J Haematol 115:272-278, 2001[CrossRef][Medline] 44. Kostakoglu L, Coleman M, Leonard JP, et al: PET predicts prognosis after 1 cycle of chemotherapy in aggressive lymphoma and Hodgkin’s disease. J Nucl Med 43:1018-1027, 2002 45. Hutchings M, Loft A, Hansen M, et al: FDG-PET after two cycles of chemotherapy predicts treatment failure and progression-free survival in Hodgkin lymphoma. Blood 107:52-59, 2006 46. Jerusalem G, Beguin Y, Fassotte MF, et al: Early detection of relapse by whole-body positron emission tomography in the follow-up of patients with Hodgkin’s disease. Ann Oncol 14:123-130, 2003 47. NCCN Practice Guidelines in Oncology, Hodgkin’s disease/Lymphoma. v1, 2006 48. Expert Panel on Radiation Oncology-Hodgkin’s Working Group: Follow-up of Hodgkin’s disease. ACR Appropriateness Criteria, 2006
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
TOP
ABSTRACT
INTRODUCTION
