The Role of Surgical Resection in Stage IIIA Non-Small Cell Lung Cancer: A Decision and Cost-Effectiveness Analysis

Abstract

Purpose To evaluate the cost-effectiveness of combination chemotherapy, radiation, and surgery (CRS) versus definitive chemotherapy and radiation (CR) in clinical Stage IIIA non-small cell lung cancer (NSCLC) patients at academic and non-academic centers. Methods Patients with clinical stage IIIA NSCLC receiving CR or CRS from 1998–2010 were identified in the National Cancer Data Base (NCDB). Propensity score matching on patient, tumor, and treatment characteristics was performed. Medicare allowable charges were used for treatment costs. The incremental cost effectiveness ratio (ICER) was based on probabilistic 5-year survival and calculated as cost per life year gained. Results 5,265 CR and CRS matched patient pairs were identified. Surgery imparted an increased effectiveness of 0.83 life years, with an ICER of $17,618. Among non-academic centers, 1,634 matched CR and CRS patients demonstrated a benefit with surgery of 0.86 life years gained, for an ICER of $17,124. At academic centers, 3,201 matched CR and CRS patients had increased survival of 0.81 life years with surgery, for an ICER of $18,144. Finally, 3,713 CRS patients were matched between academic and non-academic centers. Academic center surgical patients had an increased effectiveness of 1.5 months gained and dominated the model with lower surgical cost estimates associated with lower 30-day mortality rates. Conclusions In Stage IIIA NSCLC, the selective addition of surgery to chemoradiation is cost-effective compared to definitive chemoradiation therapy at both non-academic and academic centers. These conclusions are valid over a range of clinically meaningful variations in cost and treatment outcomes.

A Model to Predict the Use of Surgical Resection for Advanced-Stage Non-Small Cell Lung Cancer Patients

“…A routine criticism of these analyses is that selection bias (even with advanced statistical techniques such as propensity matching) remains an important confounding factor potentially accounting for superior survival outcomes observed for surgical patients [4,5,9]. This selection bias may reflect the influence of treatment-related variables that are not independently associated with the outcome variable of interest.…”

The benefits and harms of adjuvant chemotherapy for non-small cell lung cancer in patients with major comorbidities: A simulation study

“…We only evaluated patients with lobectomy, the standard treatment for stage IB-IIIA NSCLC; thus our results do not apply to patients who underwent limited resection that are at increased risk of recurrence (53, 54). Additionally, we did not assess the cost-effectiveness of adjuvant chemotherapy in patients with comorbidities, which may differ from that estimated for healthier populations with locoregional NSCLC (55, 56). We did not assess adjuvant treatment with targeted therapy, which is now indicated for patients with early-stage lung cancer with targetable mutations (11, 57, 58).…”

Management of stage IIIA non-small-cell lung cancer: role of surgery

“…A study of stage IIIA NSCLC patients in the National Cancer Database receiving either definitive chemoradiotherapy or a trimodal combination of chemotherapy, radiotherapy, and surgical resection was conducted to assess the cost-effectiveness of these management options. The study found an incremental cost increase of $14,722 in definitive chemoradiation therapy when compared to the trimodality therapy option (28). The cost of trimodality therapy is also lower when offered at academic centers versus non-academic centers (28).…”

“…The study found an incremental cost increase of $14,722 in definitive chemoradiation therapy when compared to the trimodality therapy option (28). The cost of trimodality therapy is also lower when offered at academic centers versus non-academic centers (28). There is a lack of routinely collected data in other quality of life measures for the patient population at hand.…”