Skip to main navigation menu Skip to main content Skip to site footer

Research Article

Vol. 7 No. 2 (2004)

Cost-Effectiveness of Positron Emission Tomography in Recurrent Colorectal Cancer in Canada

  • Jeffrey Scott Sloka, , M.D., Ph.D.
  • Peter Dorroch Hollett, M.D., K.
  • Maria Mathews, Ph.D.
October 27, 2020


Several studies over the past decade have demonstrated that 2-fluoro-2-D-[18F] fluorodeoxyglucose (FDG) positron emission tomography (PET) is more accurate than computed tomography (CT) for the staging of recurrent colorectal carcinoma. This study uses quantitative decision tree modeling and sensitivity analysis to assess the cost-effectiveness of a PET-based management strategy for staging recurrent colorectal carcinoma in Canada. Both management costs and life expectancy are determined. METHODS: Two patient management strategies were compared - one using CT alone and one using both CT and PET. A survey of recent literature was used to construct a meta-analyses of available studies for the accuracy of PET in staging recurrent colorectal carcinoma. Life expectancies were determined from recent Canadian statistics, and expected life expectancies with disease were calculated from published survival rates. Management costs were determined from: estimates of the installation cost of PET facilities in Canada; management costs from our institutions; and recently published Canadian cost estimates of various procedures. RESULTS: A cost savings of $1,758 per person is expected for a PET and CT strategy, along with a slight increase in life expectancy (3.8 days), when compared with a CT alone strategy. This cost savings stemmed from avoided surgeries and remained in favour of the PET strategy when subjected to a rigorous sensitivity analysis.


  1. National Cancer Institute of Canada. Canadian Cancer Statistics 2000, Toronto, Canada, 2000. 2001.
  2. Valk PE, Abella-Columna E, Haseman MK, Pounds TR, Tesar RD, Myers RW et al. Whole-body PET imaging with 18F]fluorodeoxyglucose in management of recurrent colorectal cancer. Arch Surg 1999; 134(5):503-511.
  3. Schiepers C, Penninckx F, De Vadder N, Merckx E, Mortelmans L, Bormans G et al. Contribution of PET in the diagnosis of recurrent colorectal cancer: comparison with conventional imaging. Eur J Surg Oncol 1995; 21(5):517-522.
  4. Vitola JV, Delbeke D, Sandler MP, Campbell MG, Powers TA, Wright JK et al. Positron emission tomography to stage suspected metastatic colorectal carcinoma to the liver. Am J Surg 1996; 171(1):21-26.
  5. Delbeke D, Vitola JV, Sandler MP, Arildsen RC, Powers TA, Wright JK, Jr. et al. Staging recurrent metastatic colorectal carcinoma with PET. J Nucl Med 1997; 38(8):1196-1201.
  6. Boykin KN, Zibari GB, Lilien DL, McMillan RW, Aultman DF, McDonald JC. The use of FDG-positron emission tomography for the evaluation of colorectal metastases of the liver. Am Surg 1999; 65(12):1183-1185.
  7. Fong Y, Saldinger PF, Akhurst T, Macapinlac H, Yeung H, Finn RD et al. Utility of 18F-FDG positron emission tomography scanning on selection of patients for resection of hepatic colorectal metastases. Am J Surg 1999; 178(4):282-287.
  8. Flanagan FL, Dehdashti F, Ogunbiyi OA, Kodner IJ, Siegel BA. Utility of FDG-PET for investigating unexplained plasma CEA elevation in patients with colorectal cancer. Ann Surg 1998; 227(3):319-323.
  9. Hoh CK, Schiepers C, Seltzer MA, Gambhir SS, Silverman DH, Czernin J et al. PET in oncology: will it replace the other
  10. modalities? Semin Nucl Med 1997; 27(2):94-106.
  11. Conti PS, Lilien DL, Hawley K, Keppler J, Grafton ST, Bading JR. PET and [18F]-FDG in oncology: a clinical update. Nucl
  12. Med Biol 1996; 23(6):717-735.
  13. Desch CE, Benson AB, III, Smith TJ, Flynn PJ, Krause C, Loprinzi CL et al. Recommended colorectal cancer surveillance guidelines by the American Society of Clinical Oncology. J Clin Oncol 1999; 17(4):1312.
  14. August DA, Ottow RT, Sugarbaker PH. Clinical perspective of human colorectal cancer metastasis. Cancer Metastasis Rev 1984; 3(4):303-324.
  15. Grage TB, V assilopoulos PP , Shingleton WW , Jubert A V , Elias EG, Aust JB et al. Results of a prospective randomized study of hepatic artery infusion with 5-fluorouracil versus intravenous 5- fluorouracil in patients with hepatic metastases from colorectal cancer: A Central Oncology Group study. Surgery 1979; 86(4):550-555.
  16. Macdonald JS, Kisner DF, Smythe T, Woolley PV, Smith L, Jr., Schein PS. 5-Fluorouracil (5-FU), methyl-CCNU, and vincristine in the treatment of advanced colorectal cancer: phase II study utilizing weekly 5-FU. Cancer Treat Rep 1976; 60(11):1597-1600.
  17. Buroker T, Kim PN, Groppe C, McCracken J, O'Bryan R, Panettiere F et al. 5FU infusion with mitomycin-C versus 5 FU infusion with methyl-CCNU in the treatment of advanced colon cancer: a Southwest Oncology Group Study. Cancer 1978; 42(3):1228-1233.
  18. Kemeny N, Y ounes A, Seiter K, Kelsen D, Sammarco P , Adams L et al. Interferon alpha-2a and 5-fluorouracil for advanced colorectal carcinoma. Assessment of activity and toxicity. Cancer 1990; 66(12):2470-2475.
  19. Cohen AM, Minsky BD, Schilsky RL.In: De Vita VT,Jr. Hellmann S, Rosenberg SA (eds). Cancer: principles and practice of oncology, 4th ed. Lippincott, Philadelphia, p929.
  20. Taylor I. Liver metastases from colorectal cancer: lessons from past and present clinical studies. Br J Surg 1996; 83(4):456-460.
  21. Foster JH, Lundy J. Liver Metastases. Curr Probl Surg 1981; 18(3):157-202.
  22. Fong Y, Salo J. Surgical therapy of hepatic colorectal metastasis. Semin Oncol 1999; 26(5):514-523.
  23. Johannesson M. On the estimation of cost-effectiveness ratios. Health Policy 1995; 31(3):225-229.
  24. Dsetlein M, Sheidhauer K, Lautenbach K, Schicha H. Quality criteria for cost-benefit analysis in oncological nuclear medicine. Zeitschrift fur Arzlich Fortbildung und Qualitatssichanung 93[1], 49-55. 2001.
  25. Beanlands R, Chamberlain M, Cripps C, et al. Position paper on the future of positron emission tomography in Ontario. Council of Medical Imaging, Oakville, Ontario . 2001. 1999.
  26. Institute for Clinical PET. Clinical application and economic implications of PET in the assessment of colorectal cancer recurrence: A retrospective study. ICP International Conference 2001.
  27. Chiappa A, Zbar AP, Biella F, Staudacher C. Survival after repeat hepatic resection for recurrent colorectal metastases. Hepatogastroenterology 1999; 46(26):1065-1070.
  28. Law WL, Chu KW, Ho JW, Tung HM, Law SY, Chu KM. Self- expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies. Dis Colon Rectum 2000; 43(11):1522-1527.
  29. Cheung PC, Mackillop WJ, Dixon P , Brundage MD, Y oussef YM, Zhou S. Involved-field radiotherapy alone for early-stage non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2000; 48(3):703-710.
  30. Hoffman PC, Mauer AM, Vokes EE. Lung cancer. Lancet 2000; 355(9202):479-485.
  31. Knott-Craig CJ, Howell CE, Parsons BD, Paulsen SM, Brown BR, Elkins RC. Improved results in the management of surgical candidates with lung cancer. Ann Thorac Surg 1997; 63(5):1405-1409.
  32. Durand-Zaleski I, Roche B, Buyse M, Carlson R, O'Connell MJ, Rougier P et al. Economic implications of hepatic arterial infusion chemotherapy in treatment of nonresectable colorectal liver metastases. Meta-Analysis Group in Cancer. J Natl Cancer Inst 1997; 89(11):790-795.
  33. Oxman AD, Cook DJ, Guyatt GH. Users' guides to the medical literature. VI. How to use an overview. Evidence-Based Medicine Working Group. JAMA 1994; 272(17):1367-1371.
  34. Gambhir SS. Decision analysis in nuclear medicine. J Nucl Med 1999; 40(9):1570-1581.
  35. Sox HC. Medical decision making. Butterworths . 2001. Boston.
  36. Akhurst T, Larson SM. Positron emission tomography imaging of colorectal cancer. Semin Oncol 1999; 26(5):577-583.
  37. Beets G, Penninckx F, Schiepers C, Filez L, Mortelmans L, Kerremans R et al. Clinical value of whole-body positron emission tomography with [18F]fluorodeoxyglucose in recurrent colorectal cancer. Br J Surg 1994; 81(11):1666-1670.
  38. Lai DT, Fulham M, Stephen MS, Chu KM, Solomon M, Thompson JF et al. The role of whole-body positron emission tomography with [18F]fluorodeoxyglucose in identifying operable colorectal cancer metastases to the liver. Arch Surg
  39. ; 131(7):703-707.
  40. Imdahl A, Reinhardt MJ, Nitzsche EU, Mix M, Dingeldey A, Einert A et al. Impact of 18F-FDG-positron emission tomography for decision making in colorectal cancer recurrences. Langenbecks Arch Surg 2000; 385(2):129-134.
  41. Hartman GW, Hattery RR, Witten DM, Williamson B, Jr. Mortality during excretory urography: Mayo Clinic experience. AJR Am J Roentgenol 1982; 139(5):919-922.
  42. Gambhir SS, Hoh CK, Phelps ME, Madar I, Maddahi J. Decision tree sensitivity analysis for cost-effectiveness of FDG- PET in the staging and management of non-small-cell lung carcinoma. J Nucl Med 1996; 37(9):1428-1436.
  43. Kosuda S, Ichihara K, Watanabe M, Kobayashi H, Kusano S. Decision-tree sensitivity analysis for cost-effectiveness of chest 2- fluoro-2-D-[(18)F]fluorodeoxyglucose positron emission tomography in patients with pulmonary nodules (non-small cell lung carcinoma) in Japan. Chest 2000; 117(2):346-353.
  44. Bohm B, Grundel K, Neudecker J, Schwenk W. [Can colorectal carcinomas be resected laparoscopically? Technically possible, long-term outcome is still uncertain]. MMW Fortschr Med 2000; 142(8):30-32.
  45. Baccari P, Di Palo S, Redaelli A, Carlucci M, Staudacher C. [Laparoscopic versus conventional surgery in the treatment of colorectal diseases]. Chir Ital 2000; 52(1):17-27.
  46. Bolton JS, Fuhrman GM. Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma. Ann Surg 2000; 231(5):743-751.
  47. Imamura H, Kawasaki S, Miyagawa S, Ikegami T, Kitamura H, Shimada R. Aggressive surgical approach to recurrent tumors after hepatectomy for metastatic spread of colorectal cancer to the liver. Surgery 2000; 127(5):528-535.
  48. Schiedeck TH, Schwandner O, Baca I, Baehrlehner E, Konradt J, Kockerling F et al. Laparoscopic surgery for the cure of colorectal cancer: results of a German five-center study. Dis Colon Rectum 2000; 43(1):1-8.
  49. Rosen SA, Buell JF, Yoshida A, Kazsuba S, Hurst R, Michelassi F et al. Initial presentation with stage IV colorectal cancer: how aggressive should we be? Arch Surg 2000; 135(5):530-534.
  50. Fernandez Merino FJ, Vicente LE, Nuno GJ, Zarzosa G, Barrasa SA, Meneu JC. Resection of colorectal liver metastases: analysis of risk factors. Rev Esp Enferm Dig 2000; 92(2):97- 104.
  51. Ansari MZ, Collopy BT, Hart WG, Carson NJ, Chandraraj EJ. In-hospital mortality and associated complications after bowel surgery in Victorian public hospitals. Aust N Z J Surg 2000; 70(1):6-10.
  52. Hart R, Classen M. Complications of diagnostic gastrointestinal endoscopy. Endoscopy 1990; 22(5):229-233.
  53. Sherlock S DJ. Diseases of the liver and biliary system, 10th ed. London: Blackwell Science . 2001.
  54. Kievit J. Colorectal cancer follow-up: a reassessment of empirical evidence on effectiveness. Eur J Surg Oncol 2000; 26(4):322-328.
  55. Beck JR, Kassirer JP, Pauker SG. A convenient approximation of life expectancy (the "DEALE"). I. Validation of the method. Am J Med 1982; 73(6):883-888.
  56. Beck JR, Pauker SG, Gottlieb JE, Klein K, Kassirer JP. A convenient approximation of life expectancy (the "DEALE"). II. Use in medical decision-making. Am J Med 1982; 73(6):889-897.
  57. Evans WK, Will BP, Berthelot JM, Wolfson MC. The economics of lung cancer management in Canada. Lung Cancer 1996;
  58. (1):19-29.
  59. Investigation for mediastinal disease in patients with apparently operable lung cancer. Canadian Lung Oncology Group. Ann Thorac Surg 1995; 60(5):1382-1389.
  60. Coy P, Schaafsma J, Schofield JA. The cost-effectiveness and cost-utility of high-dose palliative radiotherapy for advanced non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2000; 48(4):1025-1033.
  61. Gambhir SS, Gupta P, Shepherd JE, Allen MA, Hoh C, Maddahi J et al. MD@: a physician-friendly decision analysis tool. MD Comput 1998; 15(1):40-48.
  62. Canadian Institute for Health Information. Health Care in Canada. ISBN: 1-55392-018-X. 9-5-2002.
  63. Abdel-Nabi H, Doerr RJ, Lamonica DM, Cronin VR, Galantowicz PJ, Carbone GM et al. Staging of primary colorectal carcinomas with fluorine-18 fluorodeoxyglucose whole-body PET: correlation with histopathologic and CT findings. Radiology 1998; 206(3):755-760.


Download data is not yet available.