Avoiding Radical Surgery in Elderly Patients With Rectal Cancer Is Cost-Effective
File(s)
Accepted version
Author(s)
Type
Journal Article
Abstract
BACKGROUND: Radical surgery is associated with significant perioperative mortality in elderly and comorbid populations. Emerging data suggest for patients with a clinical complete response after neoadjuvant chemoradiotherapy that a watch-and-wait approach may provide equivalent survival and oncological outcomes.
OBJECTIVE: The purpose of this study was to compare the cost-effectiveness of watch and wait and radical surgery for patients with rectal cancer after a clinical complete response following chemoradiotherapy.
DESIGN: Decision analytical modeling and a Markov simulation were used to model long-term costs, quality-adjusted life-years, and cost-effectiveness after watch and wait and radical surgery. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters.
SETTINGS: A third-party payer perspective was adopted.
PATIENTS: Patients included in the study were a 60-year–old male cohort with no comorbidities, 80-year–old male cohorts with no comorbidities, and 80-year–old male cohorts with significant comorbidities.
INTERVENTIONS: Radical surgery and watch-and-wait approaches were studied.
MAIN OUTCOME MEASURES: Incremental cost, effectiveness, and cost-effectiveness ratio over the entire lifetime of the hypothetical patient cohorts were measured.
RESULTS: Watch and wait was more effective (60-year–old male cohort with no comorbidities = 0.63 quality-adjusted life-years (95% CI, 2.48–3.65 quality-adjusted life-years); 80-year–old male cohort with no comorbidities = 0.56 quality-adjusted life-years (95% CI, 0.52–1.59 quality-adjusted life-years); 80-year–old male cohort with significant comorbidities = 0.72 quality-adjusted life-years (95% CI, 0.34–1.76 quality-adjusted life-years)) and less costly (60-year–old male cohort with no comorbidities = $11,332.35 (95% CI, $668.50–$23,970.20); 80-year–old male cohort with no comorbidities = $8783.93 (95% CI, $2504.26–$21,900.66); 80-year–old male cohort with significant comorbidities = $10,206.01 (95% CI, $2762.014–$24,135.31)) independent of patient cohort age and comorbidity. Consequently, watch and wait was more cost-effective with a high degree of certainty (range, 69.6%–89.2%) at a threshold of $50,000/quality-adjusted life-year.
LIMITATIONS: Long-term outcomes were derived from modeled cohorts. Analysis was performed for a United Kingdom third-party payer perspective, limiting generalizability to other healthcare contexts.
CONCLUSIONS: Watch and wait is likely to be cost-effective compared with radical surgery. These findings strongly support the discussion of organ-preserving strategies with suitable patients.
OBJECTIVE: The purpose of this study was to compare the cost-effectiveness of watch and wait and radical surgery for patients with rectal cancer after a clinical complete response following chemoradiotherapy.
DESIGN: Decision analytical modeling and a Markov simulation were used to model long-term costs, quality-adjusted life-years, and cost-effectiveness after watch and wait and radical surgery. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters.
SETTINGS: A third-party payer perspective was adopted.
PATIENTS: Patients included in the study were a 60-year–old male cohort with no comorbidities, 80-year–old male cohorts with no comorbidities, and 80-year–old male cohorts with significant comorbidities.
INTERVENTIONS: Radical surgery and watch-and-wait approaches were studied.
MAIN OUTCOME MEASURES: Incremental cost, effectiveness, and cost-effectiveness ratio over the entire lifetime of the hypothetical patient cohorts were measured.
RESULTS: Watch and wait was more effective (60-year–old male cohort with no comorbidities = 0.63 quality-adjusted life-years (95% CI, 2.48–3.65 quality-adjusted life-years); 80-year–old male cohort with no comorbidities = 0.56 quality-adjusted life-years (95% CI, 0.52–1.59 quality-adjusted life-years); 80-year–old male cohort with significant comorbidities = 0.72 quality-adjusted life-years (95% CI, 0.34–1.76 quality-adjusted life-years)) and less costly (60-year–old male cohort with no comorbidities = $11,332.35 (95% CI, $668.50–$23,970.20); 80-year–old male cohort with no comorbidities = $8783.93 (95% CI, $2504.26–$21,900.66); 80-year–old male cohort with significant comorbidities = $10,206.01 (95% CI, $2762.014–$24,135.31)) independent of patient cohort age and comorbidity. Consequently, watch and wait was more cost-effective with a high degree of certainty (range, 69.6%–89.2%) at a threshold of $50,000/quality-adjusted life-year.
LIMITATIONS: Long-term outcomes were derived from modeled cohorts. Analysis was performed for a United Kingdom third-party payer perspective, limiting generalizability to other healthcare contexts.
CONCLUSIONS: Watch and wait is likely to be cost-effective compared with radical surgery. These findings strongly support the discussion of organ-preserving strategies with suitable patients.
Date Issued
2017-01-01
Date Acceptance
2017-01-01
Citation
Diseases of the Colon and Rectum, 2017, 60 (1), pp.30-42
ISSN
0012-3706
Publisher
Springer Verlag
Start Page
30
End Page
42
Journal / Book Title
Diseases of the Colon and Rectum
Volume
60
Issue
1
Copyright Statement
© 2016 The ASCRS. The final publication is available at Springer via https://dx.doi.org/10.1097/DCR.0000000000000708
Identifier
http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391871900010&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=1ba7043ffcc86c417c072aa74d649202
Subjects
Science & Technology
Life Sciences & Biomedicine
Gastroenterology & Hepatology
Surgery
Complete clinical response
Cost-effectiveness
Elderly
Neoadjuvant
Radiotherapy
Rectal
Watch and wait
COMPLETE CLINICAL-RESPONSE
TOTAL MESORECTAL EXCISION
NEOADJUVANT CHEMORADIATION THERAPY
METASTATIC COLORECTAL-CANCER
PREOPERATIVE RADIOTHERAPY
NONOPERATIVE TREATMENT
DECISION-ANALYSIS
LOCAL RECURRENCE
SURVIVAL
CHEMORADIOTHERAPY
Aged, 80 and over
Chemoradiotherapy
Cohort Studies
Comorbidity
Cost-Benefit Analysis
Decision Support Techniques
Digestive System Surgical Procedures
Humans
Insurance, Health, Reimbursement
Male
Middle Aged
Neoadjuvant Therapy
Neoplasm, Residual
Quality-Adjusted Life Years
Rectal Neoplasms
Remission Induction
United Kingdom
Watchful Waiting
1103 Clinical Sciences
Publication Status
Published
Coverage Spatial
Edinburgh, SCOTLAND