Cost-utility of two minimally-invasive surgical techniques for operable oropharyngeal cancer: transoral robotic surgery versus transoral laser microsurgery

Abstract

Background In the past few decades, a re-evaluation of treatment paradigms of head and neck cancers with a desire to spare patients the treatment-related toxicities of open surgery, has led to the development of new minimally invasive surgical techniques to improve outcomes. Besides Transoral Laser Microsurgery (TLM), a new robotic surgical technique namely Transoral Robotic Surgery (TORS) emerged for the first time as one of the two most prominent and widely used minimally invasive surgical approaches particularly for the treatment of oropharyngeal cancer, a sub-entity of head and neck cancers. Recent population-level data suggest equivalent tumor control, but different total costs, and need for adjuvant chemoradiation. A comparative analysis of these two techniques is therefore warranted from the cost-utility (C/U) point of view. Methods A cost-utility analysis for comparing TORS and TLM was performed using a decision-analytical model. The analyses adopted the perspective of a Swiss hospital. Two tertiary referral centers in Lausanne and Zurich provided data for model quantificantion. Results In the base case analysis TLM dominates TORS. This advantage remains robust, even if the costs for TORS reduce by up to 25%. TORS begins to dominate TLM, if less than 59,7% patients require adjuvant treatment, whereby in an interval between 55 and 62% cost effectiveness of TORS is sensitive to the prescription of adjuvant chemoradiation therapy (CRT). Exceeding 29% of TLM patients requiring a revision of surgical margins renders TORS more cost-effective. Conclusion Non-robotic endoscopic surgery (TLM) is more cost-effective than robotic endoscopic surgery (TORS) for the treatment of oropharyngeal cancers. However, this advantage is sensitive to various parameters, i.e.to the number of re-operations and adjuvant treatment.

Is the exoscope ready to replace the operative microscope in transoral surgery?

“…On one hand, image analysis and pattern recognition, in conjunction with multispectral filters, may allow a characterization of tissues and anatomic structures, giving adjunctive intraoperative clues to the surgeon during a given procedure. As already noted, the VITOM 3D allows intraoperative visualization of the tumor through the IMAGE 1S system, allowing better delineation of surgical margins of resection, similarly to what already described for Narrow Band Imaging (implemented within the ORBEYE system) and other bioendoscopic devices [46–50]. On the other hand, visualization of the surgical field through a monitor (or any other digital device) may favour integration of external information (e.g.…”

“…In these instances, the caseload required to progressively speed the setting-up process is rarely achieved, leading to a slow learning curve and frequent delays [48]. Moreover, even in favourable circumstances, the cost-effectiveness issue remains hotly debated and definitely represents a caveat [49]. The limited attention recently dedicated to the specific field of otolaryngology – head and neck surgery from the most part of the surgical robotic manufacturers clearly indicates the consistent number of problems faced in this arena.…”

Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps

“…Reasons explaining the low adoption rate of TORS in Germany (0.8%) are its cost, the lack of cost-covering reimbursement, and insufficient cooperation with other disciplines and hospital administration [ 31 ]. Indeed, the cost-effectiveness of TORS remains unknown in many indications, and, while it is under scrutiny in the United States, it has hardly been studied in Europe [ 32 ]. The Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) suffer from a scattered TORS availability in the region.…”

Ethical, Legal, and Financial Considerations of Artificial Intelligence in Surgery

“…The results are highly variable with some demonstrating greater cost-effectiveness of robotic surgeries overall and some finding that although the operative costs were higher, they may be mitigated or entirely outweighed when factoring in their associated reduced lengths of stays. [44][45][46][47][48][49] The development of ML algorithms currently being trialed in the health care landscape is often funded by individual researchers and their respective institutional or national research grants. 39 When evaluating the potential for a large-scale transformation of entire health care systems through the integration of AI/ML, due consideration must be offered towards determining which entity will bear this cost-the individual health system, the state, national research funding, and so forth.…”