Greta J Bridwell, David Xiao, Horiana B Grosu, Udit Chaddha, Abhinav Agrawal, Yaron B Gesthalter, Caroline M Godfrey, Kaele Leonard, Ankush P Ratwani, Rafael Paez, Jennifer D Duke, Christina Pichiarello, Michael N Kammer, David Ost, Eric L Grogan, Robert J Lentz, Fabien Maldonado, Samira Shojaee
In patients with prior or active malignancy, thoracentesis is a more cost-effective initial diagnostic strategy for malignant pleural effusion in cancers that have a PF-cytology diagnostic sensitivity of >27%. In recurrent effusion following a cytology-negative thoracentesis, thoracoscopy with pleural biopsy is more cost-effective than a second thoracentesis.
BACKGROUND: Thoracentesis with pleural fluid (PF) cytology has a sensitivity of ∼60% to diagnose malignant pleural effusion (MPE). Medical thoracoscopy with pleural biopsy has a higher diagnostic sensitivity. This study evaluates the cost-effectiveness of thoracentesis versus thoracoscopy for diagnosis of MPE in patients with prior or active malignancy.
RESEARCH QUESTION: When is thoracentesis or thoracoscopy cost-effective for the diagnosis of malignant pleural effusion in patients with prior or active malignancy?
STUDY DESIGN AND METHODS: A cost-effectiveness model was developed comparing thoracentesis with PF-cytology to medical thoracoscopy with pleural biopsy for the diagnosis of MPE in two scenarios: 1) initial evaluation of unilateral pleural effusion in patients with prior or active malignancy, 2) evaluation of a recurrent effusion following a cytology-negative thoracentesis. The primary outcome was cost per complication avoided with willingness-to-pay threshold of $10,000. One-way deterministic sensitivity analyses were conducted on all parameters. Model assumptions were established by consensus among a multicenter panel of pleural disease experts.
RESULTS: In unilateral pleural effusion and prior or active malignancy, a thoracoscopy-first diagnostic strategy resulted in 0.0311 fewer complications and cost an additional $1,890 compared to a thoracentesis-first strategy. Thoracoscopy-first strategy was more cost-effective when PF-cytology sensitivity was ≤27%. In recurrent effusion following a cytology-negative thoracentesis in patients with prior or active malignancy, a thoracoscopy-next strategy resulted in 0.0278 fewer complications and cost an additional $19 compared to the thoracentesis-next strategy. Thoracoscopy-next strategy was more cost-effective unless the second-thoracentesis PF-cytology sensitivity was above 29%.
INTERPRETATION: In patients with prior or active malignancy, thoracentesis is a more cost-effective initial diagnostic strategy for malignant pleural effusion in cancers that have a PF-cytology diagnostic sensitivity of >27%. In recurrent effusion following a cytology-negative thoracentesis, thoracoscopy with pleural biopsy is more cost-effective than a second thoracentesis.