When is a biopsy-proven diagnosis necessary before stereotactic ablative radiotherapy for lung cancer? a decision analysis
Cette étude évalue la performance d'un arbre décisionnel, développé à partir de données de la littérature scientifique (6 études, 5 056 patients), pour déterminer la stratégie thérapeutique à adopter chez les patients présentant un nodule pulmonaire solitaire suspect
Background : The practice of treating a solitary pulmonary nodule (SPN) suspicious for stage I non-small cell lung cancer (NSCLC) with stereotactic ablative radiotherapy (SABR) in the absence of pathology, is growing. In the absence of randomized evidence, the appropriate prior probability threshold of lung cancer of when such a strategy is warranted can be informed using decision analysis.
Methods : A decision tree and Markov model were constructed to evaluate the relative merits of surveillance, a PET-directed SABR strategy (without pathology), or a PET-biopsy-SABR strategy, when faced with a SPN at different prior probabilities for lung cancer. Diagnostic characteristics, as well as disease, treatment, and toxicity parameters were extracted from the literature. Deterministic analysis and probabilistic sensitivity analyses were performed to inform the appropriate lung cancer prior probability threshold between treatment strategies.
Results : In the reference case analysis, the prior probability threshold between surveillance and PET-biopsy-SABR was 17.0%; and between PET-directed SABR and PET-biopsy-SABR, the threshold was 85.0%. The latter finding was confirmed on probabilistic sensitivity analysis (85.2%; 95% CI: 80.0%–87.2%). This predicted lung cancer prior probability threshold was most sensitive to the diagnostic sensitivity of transthoracic biopsy (range: 77.2–94.0%) and the detection rate of false negatives (FN) on CT surveillance (82.4-92.3%).
Conclusion : This model suggests that if there are concerns about morbidity related to biopsy for a SPN, a PET-directed SABR strategy is warranted when the prior probability of lung cancer exceeds a point estimate of 85%.
CHEST Journal , résumé, 2013