The optimal diagnostic and staging strategy for patients with suspected lung cancer is not known.

What diagnostic and staging strategies are most cost-effective for lung cancer?

A decision model was developed using a hypothetical patient with a high probability of lung cancer. Sixteen unique permutations of bronchoscopy with fluoroscopy, radial endobronchial ultrasound (rEBUS), electromagnetic navigation, convex EBUS (cEBUS) with or without rapid-onsite evaluation (ROSE), computed tomography guided biopsy (CTBx) and surgery were evaluated. Outcomes included cost, complications, mortality, time to complete the evaluation, rate of undetected N2-3 disease at surgery, incremental cost-complication ratio (ICCR), and willingness-to-pay (WTP) thresholds. Sensitivity analyses were performed on primary outcomes.

For a peripheral lung lesion and radiographic N0 disease, the best bronchoscopy strategy costs $1,694 more than the best CTBx strategy but resulted in fewer complications (risk difference 14%). The additional cost of bronchoscopy to avoid one complication from a CTBx strategy was $12,037. The cost and cumulative complications of bronchoscopy strategies increase compared with CTBx strategies for small lesions. The cost and cumulative complications of bronchoscopy strategies decrease compared with CTBx strategies when a bronchus sign is present, but bronchoscopy remains more costly overall. For a central lesion and/or radiographic N1-3 disease, cEBUS with ROSE followed by lung biopsy with rEBUS if required, was more cost-effective than any CTBx strategy across all outcomes. Strategies with ROSE were always more cost-effective than those without, irrespective of scenario. Trade-offs also exist between different bronchoscopy strategies and optimal choices depend on the value placed on individual outcomes and WTP.

The most cost-effective strategies depend on nodal stage, lesion location, type of peripheral bronchoscopic biopsy, and the use of ROSE. For most clinical scenarios, many strategies can be eliminated and trade-offs between the remaining competitive strategies can be quantified.