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UPJ INSIGHT: Cost-effectiveness of Ultrasound for Diagnosis and Surveillance of Complex Cystic Renal Lesions
By: Aaron Oh, BA; Lokesh Bhardwaj, BS; Giovanni Cacciamani, MD, MSC, FEBU; Mihir M. Desai, MD; Vinay A. Duddalwar, MD, FRCR | Posted on: 16 Feb 2023
Oh A, Bhardwaj L, Cacciamani G, Desai MM, Duddalwar VA. Cost-effectiveness of contrast-enhanced ultrasound for diagnosis and active surveillance of complex cystic renal lesions. Urol Pract. 2023;10(1):10-19.
Study Needs and Importance
Cystic renal masses are extremely common incidental findings on imaging. A significant proportion of these remain indeterminate and in appropriate clinical circumstances may be managed by active surveillance. Recent literature suggests that even these complex cysts are often indolent and slow growing. Precise stratification of these renal cysts is critical for active surveillance as misdiagnosis can lead to underdiagnosis or overtreatment with potential for harm to the patient and improper financial resource distribution and utilization. The aim of this study was to determine the cost-effectiveness of contrast-enhanced ultrasound (ceUS), a promising imaging modality for the active surveillance of complex renal masses compared to CT and MRI.
What We Found
Our analysis found that ceUS is a cost-effective imaging modality for active surveillance of complex renal masses in 60-year-old patients. When compared to CT and MRI, ceUS resulted in the greatest number of quality-adjusted life years. We considered multiple scenarios where the rates of active surveillance varied from 10%–100% and found that ceUS became more cost-effective as the rates increased (see Table).
Table. Base-case Analysis for 60-Year-old Patient—Bosniak III
| Strategy | Total cost, $ | QALYs | ICERs | |
|---|---|---|---|---|
| 10% Active surveillance | ceCT | 14,394.00 | 7.9141 | — |
| ceUS | 14,647.06 | 7.9436 | 8,596.91 | |
| ceMRI | 15,072.11 | 7.8953 | Dominated | |
| 20% Active surveillance | ceCT | 13,988.96 | 7.8651 | — |
| ceUS | 14,234.95 | 7.8941 | 8,491.19 | |
| ceMRI | 14,632.95 | 7.8286 | Dominated | |
| 50% Active surveillance | ceCT | 12,734.68 | 7.7099 | — |
| ceUS | 12,959.54 | 7.7370 | 8,304.19 | |
| ceMRI | 13,268.73 | 7.6188 | Dominated | |
| 100% Active surveillance | ceCT | 10,818.87 | 7.4537 | — |
| ceUS | 11,009.96 | 7.4782 | 7,784.41 | |
| ceMRI | 11,159.57 | 7.2732 | Dominated | |
| Abbreviations: ceCT, contrast-enhanced computed tomography; ceMRI, contrast-enhanced magnetic resonance imaging; ceUS, contrast-enhanced ultrasound; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year. | ||||
Limitations
Due to the nature of cost-effectiveness analyses, simplifications and estimations from the medical literature are made to model complex clinical scenarios. For our analyses, we assumed the sensitivities and specificities of each imaging modality would be constant despite repeat imaging surveilling of renal masses over time. We assumed the cancer growth kinetics for someone with multiple false-negative results was the same as someone who had one false-negative result. For model simplicity, we assumed that patients who were in metastatic states of cancer were incurable.
Interpretation for Patient Care
From our results, we believe ceUS can be a viable option for the active surveillance of complex renal masses, especially cystic masses.
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