Cost–utility analysis of minimally invasive surgery for lung cancer: a randomized controlled trial

Abstract

OBJECTIVES: Minimally invasive video-assisted thoracic surgery (VATS) was first introduced in the early 1990s. For decades, numerous non-randomized studies demonstrated advantages of VATS over thoracotomy with lower morbidity and shorter hospital stay, but only recently did a randomized trial document that VATS results in lower pain scores and better quality of life. Opposing arguments for VATS have always been increased costs and concerns about oncological adequacy. In this paper, we aim to investigate the cost-effectiveness of VATS. METHODS: The study was designed as a cost–utility analysis of the first 12 months following surgery and was performed together with a clinical randomized controlled trial of VATS versus thoracotomy for lobectomy of stage 1 lung cancer during a 6-year period (2008–2014). All health-related expenses were retrieved from a national database (Statistics Denmark) including hospital readmissions, outpatient clinic visits, prescription medication costs, consultations with general practitioners, specialists, physiotherapists, psychologists and chiropractors. RESULTS: One hundred and three VATS patients and 103 thoracotomy patients were randomized. Mean costs per patient operated by VATS were 103 108 Danish Kroner (Dkr) (€13 818) and 134 945 Dkr (€18 085) by thoracotomy, making the costs for VATS 31 837 Dkr (€4267) lower than thoracotomy (P < 0.001). The difference in quality-adjusted life years gained over 52 weeks of follow-up was 0.021 (P = 0.048, 95% confidence interval −0.04 to −0.00015) in favour of VATS. The median duration of the surgical procedure was shorter after thoracotomy (79 vs 100 min; P < 0.001). The mean length of hospitalization was shorter following VATS (4.8 vs 6.7 days; P = 0.027). The use of other resources was not significantly different between groups. The costs of resources were lower in the VATS group. This difference was primarily due to reduced costs of readmissions (VATS 29 247 Dkr vs thoracotomy 51 734 Dkr; P < 0.001) and costs of outpatient visits (VATS 51 412 Dkr vs thoracotomy 61 575 Dkr; P = 0.012). CONCLUSIONS: VATS is a cost-effective alternative to thoracotomy following lobectomy for stage 1 lung cancer. Economical outcomes as measured by quality-adjusted life years were significantly better and overall costs were lower for VATS. Clinical Trial Registration Number: NCT01278888.

Systematic Review and Meta-Analysis of Community- and Choice-Based Health State Utility Values for Lung Cancer

“…For stages I-II, the pooled HSUV was 0.78 (95% CI 0.70-0.86) across 1510 individuals. There was significant heterogeneity across stage I-II studies (p < 0.01; I 2 = 92%), as results ranged from 0.62 (95% CI 0.51-0.72) [40] to 0.88 (95% CI 0.86-0.90) [47]. The pooled HSUV for stage III-IV was 0.69 (95% CI 0.65-0.73) across 4703 individuals.…”

“…Among the included studies, the number of patients included for HSUV analysis ranged from 43 to 2396. Only two of 27 studies clearly stated that missing HRQoL data were imputed or that HRQoL response was complete [37,47]. Six studies performed multiple HRQoL measurements in the same participants.…”

Robotic versus open and video-assisted thoracoscopic surgery approaches for lobectomy

“…Nevertheless, these authors reported a significantly lower cost of their minimally invasive techniques compared to the mean cost in France (P = 0.001). Conversely, VATS was found to be a cost-effective alternative compared to thoracotomy in the randomized controlled trial of Bendixen et al [47] , with a savings of €4267 (P < 0.001). Subramanian et al [48] reported that, compared to open lobectomy, RATS lobectomy was 13% more expensive (P < 0.001) and VATS lobectomy 2% less expensive (P = 0.007).…”

EORTC QLQ-C30 summary score reliably detects changes in QoL three months after anatomic lung resection for non-small cell lung cancer (NSCLC)

“…-Most of the operations were performed using VATS. The minor incidence of the post-thoracotomy pain especially in the early postoperative period has been recently reported in a large randomized trial comparing the two surgical approaches (28).…”