Cost-Effectiveness Analysis: Selective Use of Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer

Abstract

BACKGROUND:Locally advanced rectal cancer has high cure rates with trimodal therapy. Studies sparing neoadjuvant chemoradiation in selected patients show comparable outcomes. OBJECTIVE:This study aimed to determine the cost-effectiveness of selective use of neoadjuvant chemoradiation in this population. DESIGN: A cost-effectiveness analysis model compared selective and blanket use chemoradiation for locally advanced rectal cancer. SETTINGS: Literature review, expert consensus, and a prospective database populated the model. Health care utilization costs were based on information from the Centers for Medicare and Medicaid Services.PATIENTS: Adult patients with stage II and III rectal cancer were selected. MAIN OUTCOMES MEASURES:Primary outcomes were cost, effectiveness in quality-adjusted disease-free life years, net monetary benefit, and incremental cost-effectiveness ratios in dollars per quality-adjusted disease-free life years. Base-case 5-year disease-free survival for both strategies was 65%. One-way sensitivity analysis found the probability of 5-year disease-free survival for selective ranged between 40% and 65%. Probabilistic sensitivity analysis assessed second-order variability.

Patient-Relevant Costs for Organ Preservation versus Radical Resection in Locally Advanced Rectal Cancer

“…Differences occurred from various model's specifications, as we applied specific utilities and transition probabilities from the ARO-04 trial [35,42] for the base case. NOM was dominant over resection in concordance with other cost-effectiveness simulations [10][11][12][13][14]49]. The model appeared to be insensitive to changes in treatment costs or QALYs in one-way exploratory sensitivity modeling, suggesting that NOM (I) remained the preferred treatment option regarding the patient's costs and QoL even with varied parameters.…”

“…We found that both treatment options are cost-effective for the underlying WTP, but NOM (I) was more cost-effective in each simulated case. The simulated effectiveness was comparable with values reported in the literature [10][11][12][13][14]49]. Differences occurred from various model's specifications, as we applied specific utilities and transition probabilities from the ARO-04 trial [35,42] for the base case.…”

“…Assessing a patient's individual financial toxicity in such a theoretical approach is difficult due to the heterogeneity of the individual patient's situation and regional differences in health care systems. Earlier cost-effectiveness analyses for NOM were thus reporting costs from a third-party's view [10][11][12][13][14]49,50]. In the German health care system, financial toxicity was found to be the result of either treatment costs that were not covered by the health insurances (such as costs for co-payments, additional medication or driving expenses) or the loss of income [16].…”

“…Patients undergoing resection are not required to undergo these examinations so often [1]. There are several cost-effectiveness analyses consistently showing an economical benefit from a thirdparty view [10][11][12][13][14]. At this point, there are no analyses available from the patient's point of view.…”

Rectal Cancer: New Challenges

“…Surgical complications were reduced and the 3-year survival rate improved compared with historical controls receiving neoadjuvant chemoradiation. Mueller et al 11 reported a cost-effectiveness analysis of selective versus “blanket” use of chemoradiation for LARC and showed that selective use is associated with both higher quality-adjusted disease-free life years and lower cost.…”