Cost-Effectiveness Analysis of 68Ga-DOTATATE PET/MRI in Radiotherapy Planning in Patients with Intermediate-Risk Meningioma.

BACKGROUND AND PURPOSE: While contrast-enhanced MR imaging is the criterion standard in meningioma diagnosis and treatment response assessment, gallium 68Ga-DOTATATE PET/MR imaging has increasingly demonstrated utility in meningioma diagnosis and management. Integrating 68Ga-DOTATATE PET/MR imaging in postsurgical radiation planning reduces the planning target volume and organ-at-risk dose. However, 68Ga-DOTATATE PET/MR imaging is not widely implemented in clinical practice due to higher perceived costs. Our study analyzes the cost-effectiveness of 68Ga-DOTATATE PET/MR imaging for postresection radiation therapy planning in patients with intermediate-risk meningioma. MATERIALS AND METHODS: We developed a decision-analytical model based on both recommended guidelines on meningioma management and our institutional experience. Markov models were implemented to estimate quality-adjusted life-years (QALY). Cost-effectiveness analyses with willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were performed from a societal perspective. Sensitivity analyses were conducted to validate the results. Model input values were based on published literature. RESULTS: The cost-effectiveness results demonstrated that 68Ga-DOTATATE PET/MR imaging yields higher QALY (5.47 versus 5.05) at a higher cost ($404,260 versus $395,535) compared with MR imaging alone. The incremental cost-effectiveness ratio analysis determined that 68Ga-DOTATATE PET/MR imaging is cost-effective at a willingness to pay of $50,000/QALY and $100,000/QALY. Furthermore, sensitivity analyses showed that 68Ga-DOTATATE PET/MR imaging is cost-effective at $50,000/QALY ($100,000/QALY) for specificity and sensitivity values above 76% (58%) and 53% (44%), respectively. CONCLUSIONS: 68Ga-DOTATATE PET/MR imaging as an adjunct imaging technique is cost-effective in postoperative treatment planning in patients with meningiomas. Most important, the model results show that the sensitivity and specificity cost-effective thresholds of 68Ga-DOTATATE PET/MR imaging could be attained in clinical practice.

Interventional Cultural and Language Assistance Program: Associations between Cultural and Linguistic Factors and Satisfaction with Cancer Care.

Addressing language and cultural nuance is required to improve the quality of care among all patients. The tenth version of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) recommends implementing ongoing assessments to integrate specific actions into measurement and continuous quality improvement activities. To this end, we have created the Interventional Cultural and Language Assistance Program (ICLAP). As part of ICLAP, we conducted a cross-sectional needs assessment survey with 564 consecutive patients receiving outpatient Positron emission tomography-computed tomography (PET/CT) imaging at a comprehensive cancer center in the five most prevalent languages of New York City: English, Spanish, Russian, Chinese, and Arabic. The purpose of this study is to describe the language assistance characteristics and needs of a sample of patients receiving care in the cancer center. We examined the relationship between race, ethnicity, birthplace, communication and language assistance characteristics and the satisfaction with the care received. Our results show that race and ethnicity, birthplace, cultural beliefs, language assistance, and communication characteristics were all factors associated with patients' satisfaction with care, illustrating that there is an unmet need among cancer patients to have cultural and linguistic sensitive services.

Radium-223 outcomes after multiple lines of metastatic castration-resistant prostate cancer therapy in clinical practice: implication of pre-treatment spinal epidural disease.

BACKGROUND: Magnetic resonance imaging (MRI) is not routinely performed before initiating radium-223 to document spinal epidural disease. However, radium-223 decays to form α-particles with very short path lengths that may not reach the epidural space. Herein, we investigate the impact of baseline spinal epidural disease on metastatic castration-resistant prostate cancer (mCRPC) patients treated with radium-223. METHODS: Between October 2013 to December 2014, 41 consecutive mCRPC patients at a large tertiary cancer center were prescribed radium-223 as part of standard of care. 29% of patients had pre-treatment epidural disease (posMRI), 27% had no epidural disease (negMRI), and 44% did not have a baseline MRI (noMRI). All patients had post-treatment spinal imaging. Actuarial survival times were calculated for overall survival (OS), spinal axis radiographic progression-free survival (spinePFS) and epidural progression-free survival (epiPFS) from time of first radium-223 treatment. RESULTS: For patients with posMRI (n=12), noMRI (n=18) and negMRI (n=11) cumulative rates of development or worsening of epidural disease and/or high-grade cord compression at time of last follow-up were 83%, 44% and 9%, respectively (P=0.001). For the posMRI, noMRI and negMRI groups the median OS was 6.3 months, 12.6 months and not reached (P=0.01), the median spinePFS was 3.2 months, 4.8 months and not reached (P=0.01), and the median epiPFS was 3.2 months, 10.4 months and not reached (P=0.001). Completing less than six cycles of radium-223 was significantly associated with worse OS (P<0.0001), spinePFS (P=0.007) and epiPFS (P=0.01). Greater than or equal to twenty osseous lesions pre-treatment was significantly associated with worse spinePFS (P=0.001) and epiPFS (P=0.03). CONCLUSIONS: In a heavily pre-treated small cohort, patients with baseline epidural disease frequently progressed to spinal cord compression and early cessation of radium-223 therapy. Studies are needed to determine the optimal timing of radium-223 with other mCRPC therapies given the predilection for epidural disease and treatment failure after multiple prior lines of mCRPC therapy.

Cost-effective strategy for the serological investigation of coeliac disease.

Increased numbers of requests for serological investigation of coeliac disease, and a local trend to request both anti-gliadin antibodies (AGA) and anti-endomysium antibodies (AEA) simultaneously, resulted in cost pressures that prompted a review of our practice. Serology results from all patients (771 children, 511 adults) investigated for coeliac disease over a 3-year period were compared with small intestine histology where available. IgG AGA and IgA AGA were measured by enzyme-linked immunosorbent assay (in-house), IgA AEA by immunofluorescence (send-away contract). Overall diagnostic performance was as follows: AGA sensitivity 84%, specificity 88%, positive predictive value (PPV) 24%, negative predictive value (NPV) 99%; AEA sensitivity 88%, specificity 97%, PPV 65%, NPV 99%. Results showed AGA, with its high NPV, to be a suitable first-line test to exclude coeliac disease. The high specificity of AEA makes it a suitable confirmatory test when AGA is positive. Introduction of this step-wise approach to coeliac disease investigation resulted in cost savings of at least Pound Sterling 5000 per year without detriment to the clinical service.

Spontaneous vacuum pneumarthrography revisited: the significance of the vacuum phenomenon in the lateral compartment of the knee.

We report seven cases of spontaneous vacuum phenomenon of the lateral compartment of the knee. Previous reports of the vacuum phenomenon suggest that it is related to traction on a joint or the absence of an effusion. The presence of this finding on plain radiographs, or artifacts associated with it on magnetic resonance imaging, have been said to create a false-positive indication for meniscal tears, especially in the medial compartment. We describe plain radiographic, magnetic resonance, and arthroscopic findings in seven consecutive patients with vacuum phenomenon of the lateral compartment of the knee and conclude that this finding may be a true-positive indication for degenerative meniscal tears and chondrosis. The etiology of this finding and its long-term significance remains unclear.

The natural history of bone bruises. A prospective study of magnetic resonance imaging-detected trabecular microfractures in patients with isolated medial collateral ligament injuries.

We conducted a prospective study to evaluate bone bruises, or trabecular microfractures, associated with isolated medial collateral ligament injuries. Magnetic resonance imaging was performed on 65 patients with isolated medial collateral ligament injuries determined by physical examination and imaging studies. Of these 65 patients, 29 (45%) had associated trabecular microfractures. Follow-up images were completed at various intervals on 24 of these 29 patients (83%). Complete resolution of these lesions was observed in all cases. This process appears to occur as a result of gradual diffusion over a period of 2 to 4 months. Bone bruises associated with medial collateral ligament injuries are approximately one-half as common as bone bruises associated with anterior cruciate ligament injuries. However, medial collateral ligament-associated trabecular microfractures may be a better natural history model because these injuries are treated nonoperatively.