First-line [¹⁸F]F-choline PET/CT in primary hyperparathyroidism: a cost-effectiveness study from the diagnostic...

The randomized controlled multicentre APACH2 trial showed that first-line [¹⁸F]F-choline (FCH1) PET/CT is superior to [^99mTc]Tc-sestaMIBI (MIBI1) SPECT/CT for referring patients with primary hyperparathyroidism (pHPT) to effective minimally invasive parathyroidectomy (MIP). The aim of this study was to weigh this clinical gain against the increase in imaging costs.

The effectiveness criterion per imaging strategy was the rate of normocalcemia at one month post true-positive first-line imaging-guided MIP. The medico-economic analysis, carried out from the payer's perspective, integrated direct hospital costs up to 6 months after randomization. The result of the cost-effectiveness analysis was calculated in the form of an incremental cost-effectiveness ratio (ICER), establishing the average cost necessary to cure an additional person by switching from the usual MIBI1 strategy to the new FCH1 strategy. Sensitivity analyses were used to test the robustness of the ICER.

The APACH2 trial enrolled 57 patients from November 2019 to May 2022 in four centres, randomized between FCH1 (n = 29) or MIBI1 (n = 28). The differential cost between FCH1 and MIBI1 strategies was €136.5 (average cost FCH1 €3,843.5 (95% CI: 3442.5-4244.5) vs MIBI1 €3,707.0 (95% CI: 3606.9- 3807.6), p = 0.53), with a differential effectiveness of 29% (average effectiveness FCH1 85% (95% CI: 0.71-0.99) vs MIBI1 56% (95% CI: 0.36-0.76), p = 0.037). The ICER of FCH1 compared to MIBI1 was €471 for referring one additional patient to MIP followed by normocalcemia. Deterministic sensitivity analysis showed ICER to vary from €-567 to €1,507. The probabilistic sensitivity analysis showed the robustness of our finding that the FCH1 strategy is slightly more expensive but also more effective than the MIBI1 strategy.

First-line FCH PET/CT in the surgical management of pHPT allows more patients to be referred directly to successful outpatient MIP at a minimal additional cost from a health insurance point of view.