Cost Effectiveness of Watch and Wait Versus Resection in Rectal Cancer Patients with Complete Clinical Response to Neoadjuvant Chemoradiation

Abstract

Background Watch and wait (WW) protocols have gained increasing popularity for patients diagnosed with locally advanced rectal cancer and presumed complete clinical response after neoadjuvant chemoradiation. While studies have demonstrated comparable survival and recurrence rates between WW and radical surgery, the decision to undergo surgery has significant effects on patient quality of life. We sought to conduct a cost-effectiveness analysis comparing WW with abdominoperineal resection (APR) and low anterior resection (LAR) among patients with stage II/III rectal cancer. Methods In this comparative-effectiveness study, we built Markov microsimulation models to simulate disease progression, death, costs, and quality-adjusted life-years (QALYs) for WW or APR/LAR. We assessed cost effectiveness using the incremental cost-effectiveness ratio (ICER), with ICERs under $100,000/QALY considered cost effective. Probabilities of disease progression, death, and health utilities were extracted from published, peer-reviewed literature. We assessed costs from the payer perspective. Results WW dominated both LAR and APR at a willingness to pay (WTP) threshold of $100,000. Our model was most sensitive to rates of distant recurrence and regrowth after WW. Probabilistic sensitivity analysis demonstrated that WW was the dominant strategy over both APR and LAR over 100% of iterations across a range of WTP thresholds from $0–250,000. Conclusions Our study suggests WW could reduce overall costs and increase effectiveness compared with either LAR or APR. Additional clinical research is needed to confirm the clinical efficacy and cost effectiveness of WW compared with surgery in rectal cancer.

Management of rectal cancer in the era of total neoadjuvant therapy and watch and wait: A multidisciplinary team discussion at the Australasian Gastro‐Intestinal Trials Group (AGITG) Annual Scientific Meeting 2022

“…32 It is also accepted that in selected patients who meet the criteria for cCR and in the context of a structured surveillance program, a nonoperative organ preservation strategy may be reasonably offered to patients and is cost-effective. 4,[33][34][35][36] Patients with sustained cCR, if managed nonoperatively, benefit by avoiding the morbidity of surgery and having an improved quality of life compared with patients who had neoadjuvant treatment and surgery. 37 There appears to be little difference in long-term survival overall if a nonoperative management strategy is pursued rather than surgery in patients who achieve cCR, as these patients have a good oncological prognosis either way.…”

“…It is also accepted that in selected patients who meet the criteria for cCR and in the context of a structured surveillance program, a nonoperative organ preservation strategy may be reasonably offered to patients and is cost‐effective 4 , 33 – 36 . Patients with sustained cCR, if managed nonoperatively, benefit by avoiding the morbidity of surgery and having an improved quality of life compared with patients who had neoadjuvant treatment and surgery 37 .…”

ASO Author Reflections: Bang for Your Buck—Implications of the Cost-Effectiveness of Watchful Waiting Versus Radical Surgery for Locally Advanced Rectal Cancer After Successful Neoadjuvant Chemoradiation

“…3,4 We used Markov modeling to show that WW was less expensive and offered greater health utility compared with TME. 5…”

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

“…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.…”