28 A Cost-Utility Analysis Comparing Indocyanine Green to Methylene Blue Dye in Axillary Lymphatic Mapping and Sentinel Lymph Node Biopsy for Breast Cancer

Background

Sentinel lymph node biopsy (SLNB) is commonly used for axillary staging in breast cancer surgery. Traditional methods include technetium-99m, lymphazurin, methylene blue (MB), or a combination. Indocyanine green (ICG) has emerged as a safe and effective alternative with fewer complications. This study compares the cost-effectiveness of MB vs ICG in performing a SLNB for breast cancer.

Materials and Methods

A systematic PubMed review identified the success and complication rates for MB and ICG in SLNB. Costs of successful breast cancer surgeries with SLNB and related complications were estimated using CMS rates via CPT and DRG codes. Utility scores from the literature were used to calculate quality-adjusted life years (QALYs). A decision tree model was developed to determine the incremental cost-effectiveness ratio (ICER). One-way (deterministic) and Monte Carlo (probabilistic) sensitivity analyses were performed to assess uncertainty. The willingness-to-pay (WTP) threshold was set to $50,000/QALY.

Results

SLNB using ICG was $287 more expensive than MB but yielded an additional 0.07 QALY, resulting in an ICER of $4,044.44, well below the WTP threshold. One-way sensitivity analysis showed SLNB with ICG became cost-ineffective if the probability of complication exceeded 4.9% or if ICG costs exceeded $4,190 per vial. SLNB with MB became cost-effective if the likelihood of complication dropped below 2.6%. Monte Carlo analysis indicated an 80% probability that SLNB with ICG is the more cost-effective option (Figure).

Conclusions

Given lower complication rates despite its higher up-front cost, ICG proved more cost-effective compared with MB in SLNB for breast cancer due to its improved quality-adjusted outcomes.