Abstract
Background
Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade
cystic lesions from those at greater risk for pancreatic cancer, raising a concern
for overtreatment.
Methods
We developed a Markov decision model to determine the cost-effectiveness of guideline-based
management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted
life year gained and survival were calculated for current management guidelines. A
sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment
of low-grade cysts is avoided, and the sensitivity and specificity thresholds required
of methods of cyst stratification to improve costs expended.
Results
“Surveillance” using current management guidelines had an incremental cost-effectiveness
ratio of $171,143/quality adjusted life year compared with no surveillance or operative
treatment (“do nothing”). An incremental cost-effectiveness ratio for surveillance
decreases to $80,707/quality adjusted life year if the operative overtreatment of
low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality
adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for
surveillance to be preferred over surgery and “do nothing.” Changes in sensitivity
alone cannot make surveillance cost-effective. Most importantly, survival in surveillance
is worse than “do nothing” for 3 years after cyst diagnosis, although long-term survival
is improved. The disadvantage is eliminated when overtreatment of low-grade cysts
is avoided.
Conclusion
Current management of pancreatic cystic lesions is not cost-effective and may increase
mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification
for high-risk cysts must be greater than 67% to make surveillance cost-effective.
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Article info
Publication history
Published online: July 29, 2020
Accepted:
April 20,
2020
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
