Cost-utility analysis of preoperative radiotherapy in patients with rectal cancer undergoing total mesorectal excision: a study of the Dutch Colorectal Cancer Group

Effect of neoadjuvant therapy on textbook outcomes in minimally invasive rectal cancer surgery

AIM

Textbook outcome (TO), a combined quality indicator, encompasses key postoperative indicators such as the absence of complications, R0 resection, and no prolonged length of day. It has been suggested to be of additional value over single outcome parameters in short-term outcomes of surgical treatment. The main objective of this research was to assess the relationship between TO and neoadjuvant therapy (NT), thereby providing insights into NT's role in surgical quality.

METHOD

Patients who underwent minimally invasive rectal surgery were enrolled between January 2019 and June 2024. TO was defined as achieving R0 resection, at least 12 lymph nodes harvested, no adverse outcomes (Clavien-Dindo score ≥ 3, readmission, or mortality within 30 days), and length of stay within the ≤ 75th percentile for the treatment year. The relationship between TO and NT was analyzed using regression analyses. Subgroup analysis and hierarchical regression were conducted to investigate potential influencing factors and interactions.

RESULTS

405 patients were enrolled, with 204 achieving TO. NT was associated with a reduction in TO (OR: 0.37, 95% CI: 0.21 ~ 0.65, p < 0.001), while robotic surgery (OR: 2.88, 95% CI: 1.62 ~ 5.11), total laparoscopic surgery (OR: 2.79, 95% CI: 1.71 ~ 4.56), enhanced recovery after surgery (OR: 1.62, 95% CI: 1.02 ~ 2.59), and stoma (OR: 1.87, 95% CI: 1.18 ~ 2.96) were associated with an increased rate of TO. The impact of NT on TO varied depending on surgery duration; prolonged surgical time exacerbated the negative effect of NT on TO. This observation was consistent with a significant interaction effect.

CONCLUSION

NT is associated with a lower TO rate, especially in patients with prolonged surgical time. Robotic surgery, total laparoscopic surgery, enhanced recovery after surgery, and stoma can improve achieve TO.

Cost-Effectiveness of Total Neoadjuvant Therapy With Selective Nonoperative Management for Locally Advanced Rectal Cancer: Analysis of Data From the Organ Preservation for Rectal Adenocarcinoma Trial

PURPOSE

The clinical efficacy of total neoadjuvant therapy (TNT) followed by selective nonoperative management (NOM) for locally advanced rectal cancer (LARC) was examined in the Organ Preservation for Rectal Adenocarcinoma (OPRA) trial. We investigated the cost and quality-of-life implications of adopting this treatment approach.

METHODS

We analyzed clinical, cost, and quality-of-life outcomes for TNT with selective NOM in comparison with chemoradiotherapy (CRT)-surgery-adjuvant chemotherapy (standard of care [SOC]) using data from OPRA, prospective cohorts, and published studies. Cost-effectiveness was evaluated over varying willingness-to-pay thresholds, and sensitivity analyses evaluated cost-effectiveness for different surgical contexts and SOC variants as well as a 10-year time horizon.

RESULTS

SOC was dominated by TNT with selective NOM in the base case analysis. TNT in which CRT was followed by consolidation chemotherapy (CNCT) was the least costly at $89,712 in Medicare proportionate US dollars (MP$), followed by TNT in which induction chemotherapy was followed by CRT (INCT) at MP$90,259 and SOC at MP$98,755. INCT was the preferred strategy, with 4.56 quality-adjusted life years, followed by CNCT at 4.42 and SOC at 4.29. TNT with selective NOM dominated SOC in all sensitivity analyses except when SOC omitted adjuvant chemotherapy without an impact on disease-free survival. CNCT was more cost effective than SOC when the proportion of patients entering NOM after TNT was ≥22% or ≥43%, for SOC with and without adjuvant therapy, both well below the rates seen in OPRA.

CONCLUSION

TNT with selective NOM is cost effective. The cost-effectiveness of CNCT with NOM relative to SOC is dependent on CNCT being made available to a sufficiently large proportion of patients with LARC. Additional analyses are needed to validate these findings from a societal perspective and in the context of other emerging treatment paradigms for LARC.

Economic Evaluation of 'Watch and Wait' Following Neoadjuvant Therapy in Locally Advanced Rectal Cancer: A Systematic Review

BACKGROUND

Owing to multimodal treatment and complex surgery, locally advanced rectal cancer (LARC) exerts a large healthcare burden. Watch and wait (W&W) may be cost saving by removing the need for surgery and inpatient care. This systematic review seeks to identify the economic impact of W&W, compared with standard care, in patients achieving a complete clinical response (cCR) following neoadjuvant therapy for LARC.

METHODS

The PubMed, OVID Medline, OVID Embase, and Cochrane CENTRAL databases were systematically searched from inception to 26 April 2024. All economic evaluations (EEs) that compared W&W with standard care were included. Reporting and methodological quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), BMJ and Philips checklists. Narrative synthesis was performed. Primary and secondary outcomes were (incremental) cost-effectiveness ratios and the net financial cost.

RESULTS

Of 1548 studies identified, 27 were assessed for full-text eligibility and 12 studies from eight countries (2016-2024) were included. Seven cost-effectiveness analyses (complete EEs) and five cost analyses (partial EEs) utilized model-based (n = 7) or trial-based (n = 5) analytics with significant variations in methodological design and reporting quality. W&W showed consistent cost effectiveness (n = 7) and cost saving (n = 12) compared with surgery from third-party payer and patient perspectives. Critical parameters identified by uncertainty analysis were rates of local and distant recurrence in W&W, salvage surgery, perioperative mortality and utilities assigned to W&W and surgery.

CONCLUSION

Despite heterogenous methodological design and reporting quality, W&W is likely to be cost effective and cost saving compared with standard care following cCR in LARC. Clinical Trials Registration PROSPERO CRD42024513874.

Early evaluation of the effectiveness and cost-effectiveness of ctDNA-guided selection for adjuvant chemotherapy in stage II colon cancer

Background

Current patient selection for adjuvant chemotherapy (ACT) after curative surgery for stage II colon cancer (CC) is suboptimal, causing overtreatment of high-risk patients and undertreatment of low-risk patients. Postoperative circulating tumor DNA (ctDNA) could improve patient selection for ACT.

Objectives

We conducted an early model-based evaluation of the (cost-)effectiveness of ctDNA-guided selection for ACT in stage II CC in the Netherlands to assess the conditions for cost-effective implementation.

Methods

A validated Markov model, simulating 1000 stage II CC patients from diagnosis to death, was supplemented with ctDNA data. Five ACT selection strategies were evaluated: the current guideline (pT4, pMMR), ctDNA-only, and three strategies that combined ctDNA status with pT4 and pMMR status in different ways. For each strategy, the costs, life years, quality-adjusted life years (QALYs), recurrences, and CC deaths were estimated. Sensitivity analyses were performed to assess the impact of the costs of ctDNA testing, strategy adherence, ctDNA as a predictive biomarker, and ctDNA test performance.

Results

Model predictions showed that compared to current guidelines, the ctDNA-only strategy was less effective (+2.2% recurrences, -0.016 QALYs), while the combination strategies were more effective (-3.6% recurrences, +0.038 QALYs). The combination strategies were not cost-effective, since the incremental cost-effectiveness ratio was €67,413 per QALY, exceeding the willingness-to-pay threshold of €50,000 per QALY. Sensitivity analyses showed that the combination strategies would be cost-effective if the ctDNA test costs were lower than €1500, or if ctDNA status was predictive of treatment response, or if the ctDNA test performance improved substantially.

Conclusion

Adding ctDNA to current high-risk clinicopathological features (pT4 and pMMR) can improve patient selection for ACT and can also potentially be cost-effective. Future studies should investigate the predictive value of post-surgery ctDNA status to accurately evaluate the cost-effectiveness of ctDNA testing for ACT decisions in stage II CC.

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

Total neoadjuvant therapy (TNT) is an evolving treatment schedule for locally advanced rectal cancer (LARC), allowing for organ preservation in a relevant number of patients in the case of complete response. Patients who undergo this so-called "watch and wait" approach are likely to benefit regarding their quality of life (QoL), especially if definitive ostomy could be avoided. In this work, we performed the first cost-effectiveness analysis from the patient perspective to compare costs for TNT with radical resection after neoadjuvant chemoradiation (CRT) in the German health care system. Individual costs for patients insured with a statutory health insurance were calculated with a Markov microsimulation. A subgroup analysis from the prospective "FinTox" trial was used to calibrate the model's parameters. We found that TNT was less expensive (-1540 EUR) and simultaneously resulted in a better QoL (+0.64 QALYs) during treatment and 5-year follow-up. The average cost for patients under TNT was 4711 EUR per year, which was equivalent to 3.2% of the net household income. CRT followed by resection resulted in higher overall costs for ostomy care, medication and greater loss of earnings. Overall, TNT appeared to be more efficacious and cost-effective from a patient's point of view in the German health care system.

Cost-effectiveness of Total Neoadjuvant Therapy With Short-Course Radiotherapy for Resectable Locally Advanced Rectal Cancer

IMPORTANCE

Short-course radiotherapy and total neoadjuvant therapy (SCRT-TNT) followed by total mesorectal excision (TME) has emerged as a new treatment paradigm for patients with locally advanced rectal adenocarcinoma. However, the economic implication of this treatment strategy has not been compared with that of conventional long-course chemoradiotherapy (LCCRT) followed by TME with adjuvant chemotherapy.

OBJECTIVE

To perform a cost-effectiveness analysis of SCRT-TNT vs LCCRT in conjunction with TME for patients with locally advanced rectal cancer.

DESIGN, SETTING, AND PARTICIPANTS

A decision analytical model with a 5-year time horizon was constructed for patients with biopsy-proven, newly diagnosed, primary locally advanced rectal adenocarcinoma treated with SCRT-TNT or LCCRT. Markov modeling was used to model disease progression and patient survival after treatment in 3-month cycles. Data on probabilities and utilities were extracted from the literature. Costs were evaluated from the Medicare payer's perspective in 2020 US dollars. Sensitivity analyses were performed for key variables. Data were collected from October 3, 2020, to January 20, 2021, and analyzed from November 15, 2020, to April 25, 2021.

EXPOSURES

Two treatment strategies, SCRT-TNT vs LCCRT with adjuvant chemotherapy, were compared.

MAIN OUTCOMES AND MEASURES

Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefits. Effectiveness was defined as quality-adjusted life-years (QALYs). Both costs and QALYs were discounted at 3% annually. Willingness-to-pay threshold was set at $50 000/QALY.

RESULTS

During the 5-year horizon, the total cost was $41 355 and QALYs were 2.21 for SCRT-TNT; for LCCRT, the total cost was $54 827 and QALYs were 2.12, resulting in a negative incremental cost-effectiveness ratio (-$141 256.77). The net monetary benefit was $69 300 for SCRT-TNT and $51 060 for LCCRT. Sensitivity analyses using willingness to pay at $100 000/QALY and $150 000/QALY demonstrated the same conclusion.

CONCLUSIONS AND RELEVANCE

These findings suggest that SCRT-TNT followed by TME incurs lower cost and improved QALYs compared with conventional LCCRT followed by TME and adjuvant chemotherapy. These data offer further rationale to support SCRT-TNT as a novel cost-saving treatment paradigm in the management of locally advanced rectal cancer.

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

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.

Early Cost-effectiveness Analysis of Risk-Based Selection Strategies for Adjuvant Treatment in Stage II Colon Cancer: The Potential Value of Prognostic Molecular Markers

BACKGROUND

To explore the potential value of consensus molecular subtypes (CMS) in stage II colon cancer treatment selection, we carried out an early cost-effectiveness assessment of a CMS-based strategy for adjuvant chemotherapy.

METHODS

We used a Markov cohort model to evaluate three selection strategies: (i) the Dutch guideline strategy (MSS+pT4), (ii) the mutation-based strategy (MSS plus a BRAF and/or KRAS mutation or MSS plus pT4), and (iii) the CMS-based strategy (CMS4 or pT4). Outcomes were number of colon cancer deaths per 1,000 patients, total discounted costs per patient (pp), and quality-adjusted life-years (QALY) pp. The analyses were conducted from a Dutch societal perspective. The robustness of model predictions was assessed in sensitivity analyses. To evaluate the value of future research, we performed a value of information (VOI) analysis.

RESULTS

The Dutch guideline strategy resulted in 8.10 QALYs pp and total costs of €23,660 pp. The CMS-based and mutation-based strategies were more effective and more costly, with 8.12 and 8.13 QALYs pp and €24,643 and €24,542 pp, respectively. Assuming a threshold of €50,000/QALY, the mutation-based strategy was considered as the optimal strategy in an incremental analysis. However, the VOI analysis showed substantial decision uncertainty driven by the molecular markers (expected value of partial perfect information: €18M).

CONCLUSIONS

On the basis of current evidence, our analyses suggest that the mutation-based selection strategy would be the best use of resources. However, the extensive decision uncertainty for the molecular markers does not allow selection of an optimal strategy at present.

IMPACT

Future research is needed to eliminate decision uncertainty driven by molecular markers.

Cost-Effectiveness and Quality-Adjusted Survival of Watch and Wait After Complete Response to Chemoradiotherapy for Rectal Cancer

BACKGROUND

Neoadjuvant chemoradiotherapy (CRT) followed by total mesorectal excision (TME) is the standard treatment for locally advanced rectal cancer. There is interest in deescalating local therapy after a clinical complete response to CRT. We hypothesized that a watch-and-wait (WW) strategy offers comparable cancer-specific survival, superior quality-adjusted survival, and reduced cost compared with upfront TME.

METHODS

We developed a decision-analytic model to compare WW, low anterior resection, and abdominoperineal resection for patients achieving a clinical complete response to CRT. Rates of local regrowth, pelvic recurrence, and distant metastasis were derived from series comparing WW with TME after pathologic complete response. Lifetime incremental costs and quality-adjusted life-years (QALY) were calculated between strategies, and sensitivity analyses were performed to study model uncertainty.

RESULTS

The base case 5-year cancer-specific survival was 93.5% (95% confidence interval [CI] = 91.5% to 94.9%) on a WW program compared with 95.9% (95% CI = 93.6% to 97.4%) after upfront TME. WW was dominant relative to low anterior resection, with cost savings of $28 500 (95% CI = $22 200 to $39 000) and incremental QALY of 0.527 (95% CI = 0.138 to 1.125). WW was also dominant relative to abdominoperineal resection, with a cost savings of $32 100 (95% CI = $21 800 to $49 200) and incremental QALY of 0.601 (95% CI = 0.213 to 1.208). WW remained dominant in sensitivity analysis unless the rate of surgical salvage fell to 73.0%.

CONCLUSIONS

Using current multi-institutional recurrence estimates, we observed comparable cancer-specific survival, superior quality-adjusted survival, and decreased costs with WW compared with upfront TME. Upfront TME was preferred when surgical salvage rates were low.

Model-based effectiveness and cost-effectiveness of risk-based selection strategies for adjuvant chemotherapy in Dutch stage II colon cancer patients

BACKGROUND

We aimed to evaluate the cost-effectiveness of risk-based strategies to improve the selection of surgically treated stage II colon cancer (CC) patients for adjuvant chemotherapy.

METHODS

Using the 'Personalized Adjuvant TreaTment in EaRly stage coloN cancer' (PATTERN) model, we evaluated five selection strategies: (1) no chemotherapy, (2) Dutch guideline recommendations assuming observed adherence, (3) Dutch guideline recommendations assuming perfect adherence, (4) biomarker mutation OR pT4 stage strategy in which patients with MSS status combined with a pT4 stage or a mutation in BRAF and/or KRAS receive chemotherapy assuming perfect adherence and (5) biomarker mutation AND pT4 stage strategy in which patients with MSS status combined with a pT4 stage tumor and a BRAF and/or KRAS mutation receive chemotherapy assuming perfect adherence. Outcomes were number of CC deaths per 1000 patients and total discounted costs and quality-adjusted life-years (QALYs) per patient (pp). Analyses were conducted from a societal perspective. The robustness of model predictions was assessed in sensitivity analyses.

RESULTS

The reference strategy, that is, no adjuvant chemotherapy, resulted in 139 CC deaths in a cohort of 1000 patients, 8.077 QALYs pp and total costs of €22,032 pp. Strategies 2-5 were more effective (range 8.094-8.217 QALYs pp and range 118-136 CC deaths per 1000 patients) and more costly (range €22,404-€25,102 pp). Given a threshold of €50,000/QALY, the optimal use of resources would be to treat patients with either the full adherence strategy and biomarker mutation OR pT4 stage strategy.

CONCLUSION

Selection of stage II CC patients for chemotherapy can be improved by either including biomarker status in the selection strategy or by improving adherence to the Dutch guideline recommendations.

Trajectories of sickness absence and disability pension before and after colorectal cancer: A Swedish longitudinal population-based matched cohort study

Objectives

Working-aged colorectal cancer (CRC) patients have a much better survival, indicating the importance of their future work situation. We investigated trajectories of sickness absence and disability pension (SADP) days before and after CRC diagnosis, and risk factors associated with different trajectories.

Methods

A longitudinal, population-based matched cohort study of 4735 CRC survivors in Sweden aged 19–62 when first diagnosed with CRC in 2008–2011, and 18,230 matched references was conducted, using microdata linked from several nationwide registers. The annual SADP net days for 2 years before through 5 years after diagnosis date were computed. A group-based trajectory model was used to depict SADP trajectories. Associations between trajectory membership, and sociodemographic and clinical variables were tested by chi² test and multinomial logistic regression.

Results

Four trajectories of SADP days/year for CRC survivors were identified: “only increase around diagnosis” (52% of all), “slight increase after diagnosis” (27%), “high then decrease moderately after diagnosis” (13%), and “constantly very high” (8%). Educational level, Charlson’s Comorbidity Index, and prediagnostic mental disorders were the strongest factors determining the SADP trajectory groups. In references, three trajectories (“constantly low” (80% of all), “constantly moderate and decrease gradually” (12%), and “very high then decrease overtime” (8%)) were identified.

Conclusion

Approximately 80% of CRC survivors return to a low level of SADP at 5 years postdiagnosis. Prediagnostic status of mental disorders, somatic comorbidity, and low educational level are good indicators of future high SADP levels for them. CRC survivors will benefit from early rehabilitation programs with identified risk factors.

Model-based evaluation of the cost effectiveness of 3 versus 6 months' adjuvant chemotherapy in high-risk stage II colon cancer patients

BACKGROUND

Our aim was to evaluate the cost effectiveness of 3 months' adjuvant chemotherapy versus 6 months in high-risk (T4 stage + microsatellite stable) stage II colon cancer (CC) patients.

METHODS

Using the validated PATTERN Markov cohort model, which simulates the disease progression of stage II CC patients from diagnosis to death, we first evaluated a reference strategy in which high-risk patients were treated with chemotherapy for 6 months. In the second strategy, treatment duration was shortened to 3 months. Both strategies were evaluated for CAPOX (capecitabine plus oxaliplatin) and FOLFOX (fluorouracil, leucovorin and oxaliplatin). Based on trial data, we assumed that shortened treatment duration compared with a 6-month regimen was equally effective for CAPOX and less effective for FOLFOX. Adverse events were highest in the 6-month strategy. Analyses were conducted from a societal perspective using a lifelong time horizon. Outcomes were number of CC deaths per 1000 patients and total discounted costs and quality-adjusted life-years (QALYs) per patient (pp). Incremental net monetary benefit (iNMB) was calculated using a willingness-to-pay value of €50,000/QALY.

RESULTS

For CAPOX, the 6-month strategy resulted in 316 CC deaths per 1000 patients, 6.71 QALYs pp and total costs of €41,257 pp. The 3-month strategy resulted in an equal number of CC deaths, but higher QALYs (6.80 pp) and lower costs (€37,645 pp), leading to a iNMB of €8454 per person for 3 months versus 6 months. For FOLFOX, the 6-month strategy resulted in 316 CC deaths per 1000 patients, 6.71 QALYs pp and total costs of €47,135 pp. The 3-month strategy resulted in more CC deaths (393), lower QALYs (6.19 pp) and lower costs (€44,389 pp). An iNMB of -€23,189 was found for 3 months versus 6 months.

CONCLUSION

Our findings indicate that 3 months' adjuvant chemotherapy should be considered as standard of care in high-risk stage II CC patients for CAPOX, but not for FOLFOX.

Nonoperative Management Versus Radical Surgery of Rectal Cancer After Neoadjuvant Therapy-Induced Clinical Complete Response: A Markov Decision Analysis

BACKGROUND

Nonoperative management of rectal cancer was introduced for patients with clinical complete response after neoadjuvant chemoradiotherapy to avoid short- and long-term surgical morbidity related to radical resection.

OBJECTIVE

The purpose of this study was to determine the expected life-years and quality-adjusted life-years for nonoperative management and radical resection of locally advanced rectal cancer after clinical complete response following neoadjuvant chemoradiotherapy.

DESIGN

Markov modeling was used to simulate nonoperative management and radical surgery for a base case scenario over a 10-year time horizon. Estimates for various clinical variables were obtained after extensive literature search. Outcome was expressed in both life-years and quality-adjusted life-years. Deterministic sensitivity analyses were completed to assess the impact of variation in key parameters.

SETTING

A decision model using a Markov model was designed.

PATIENTS

The base case was a 65-year-old man with a distal rectal tumor who had achieved clinical complete response after neoadjuvant chemoradiotherapy.

MAIN OUTCOME MEASURES

Life-years and quality-adjusted life-years were measured.

RESULTS

Quality-adjusted life-years (5.79 for nonoperative management vs 5.62 for radical surgery) and life-years (6.92 for nonoperative management vs 6.96 for radical surgery) were similar between nonoperative management and radical surgery. The preferred treatment strategy changed with variations in the probability of local regrowth in nonoperative management, the probability of salvage surgery for regrowth in nonoperative management, utilities associated with nonoperative management and low anterior resection, and the utility of low anterior resection syndrome. The model was not sensitive to (dis)utilities associated with stoma, chemotherapy, or postoperative morbidity and mortality.

LIMITATIONS

The study was limited by assumptions inherent to modeling studies.

CONCLUSIONS

Nonoperative management and radical surgery resulted in similar (quality-adjusted) life-years. Nonoperative management should therefore be considered as a reasonable treatment option. See Video Abstract at http://links.lww.com/DCR/B246. MANEJO NO-QUIRÚRGICO VERSUS CIRUGÍA RADICAL DEL CÁNCER RECTAL DESPUÉS DE LA RESPUESTA CLÍNICA COMPLETA INDUCIDA POR TERAPIA NEOADYUVANTE: UN ANÁLISIS DE DECISIÓN DE MARKOV: Se introdujo el tratamiento no quirúrgico del cáncer rectal para pacientes con respuesta clínica completa después de la quimiorradioterapia neoadyuvante para evitar la morbilidad quirúrgica a corto y largo plazo relacionada con la resección radical.Determinar los años de vida esperados y los años de vida ajustados por calidad para el tratamiento no-quirúrgico y la resección radical del cáncer rectal localmente avanzado, después de la respuesta clínica completa siguiente de la quimiorradioterapia neoadyuvante.El modelo de Markov se usó para simular el manejo no-quirúrgico y la cirugía radical para un escenario de caso base en un horizonte temporal de 10 años. Se obtuvieron estimaciones para diversas variables clínicas después de una extensa búsqueda bibliográfica. El resultado se expresó tanto en años de vida como en años de vida ajustados por calidad. Se completaron análisis determinísticos de sensibilidad para evaluar el impacto de la variación en los parámetros clave.Se diseñó un modelo de decisión utilizando un modelo de Markov.El caso base fue un hombre de 65 años con un tumor rectal distal que había logrado una respuesta clínica completa después de la quimiorradioterapia neoadyuvante.Años de vida y años de vida ajustados por calidad.Los años de vida ajustados por calidad (5.79 para el tratamiento no-quirúrgico frente a 5.62 para la cirugía radical) y los años de vida (6.92 para el tratamiento no-quirúrgico frente a 6.96 para la cirugía radical) fueron similares entre el tratamiento no-quirúrgico y la cirugía radical. La estrategia de tratamiento preferida cambió con las variaciones en la probabilidad de nuevo crecimiento local en el manejo no-operatorio, la probabilidad de cirugía de rescate para el rebrote en el manejo no-operatorio, las utilidades asociadas con el manejo no-operatorio, y la resección anterior baja y la utilidad de el syndrome de resección anterior baja. El modelo no era sensible a las (des) utilidades asociadas con el estoma, la quimioterapia o la morbilidad y mortalidad postoperatorias.El estudio estuvo limitado por suposiciones inherentes a los estudios de modelado.El manejo no-quirúrgico y la cirugía radical resultaron en años de vida similares (ajustados por calidad). Por lo tanto, el tratamiento no-quirúrgico debe considerarse como una opción de tratamiento razonable. Consulte Video Resumen en http://links.lww.com/DCR/B246.

Cost-effectiveness analysis of long-course oxaliplatin and bolus of fluorouracil based preoperative chemoradiotherapy vs. 5x5Gy radiation plus FOLFOX4 for locally advanced resectable rectal cancer

PURPOSE

To evaluate the cost-effectiveness of preoperative short-course radiotherapy (SCRT, 5 × 5 Gy) plus FOLFOX4 versus long-course oxaliplatin and bolus of fluorouracil based preoperative long-course chemoradiotherapy (LCCRT, 50.4 Gy in 28 fractions) in the management of cT4 or advanced cT3 rectal cancer (RC), both of which have been reported to achieve similar clinical effect in the NCT00833131 trial.

MATERIALS AND METHODS

A Markov decision-analytic model compared SCRT plus chemotherapy and LCCRT, by simulating three health states (disease-free survival (DFS), progressive disease (PD) and death). The primary outcomes were quality-adjusted life months (QALMs), costs, and incremental cost-effectiveness ratios (ICERs). Transition probabilities were based on the NCT00833131 trial. The costs were calculated from a Chinese payers' perspective. Strategies were evaluated with a willingness-to-pay (WTP) threshold of $2370.47 (3 × GDP) per QALM gained. Sensitivity analysis was performed to model uncertainty in these parameters.

RESULTS

The overall costs for SCRT plus chemotherapy and LCCRT were $78,937 and $38,140 with effectiveness of 29.92 QALMs and 22.99 QALMs, respectively. SCRT plus chemotherapy increased costs and QALM by $40,797.34 and 6.93 compared to LCCRT, resulting in an ICER of $5884.56/QALM gained. In the DFS state, the whole cost for SCRT plus chemotherapy and LCCRT were $11,490.03 and $10,794.06 with an effectiveness of 21.70 QALMs and 19.65 QALMs, respectively. SCRT plus chemotherapy increased cost and QALM by $695.97 and 2.05 compared to LCCRT, resulting in a ICER of $339.50/QALM gained, which below the WTP. The utility associated with the DFS state was the most influential factor on the cost-effectiveness of SCRT plus chemotherapy. When the cost of PD state below $1920, the ICER of SCRT compared with LCCRT below the WTP.

CONCLUSION

Compared with LCCRT, SCRT plus chemotherapy is a more cost-effective strategy for locally advanced resectable RC in the DFS state as well as in the all states when the cost of PD state below $1920.

Preoperative radiotherapy and curative surgery for the management of localised rectal carcinoma

BACKGROUND

This is an update of the original review published in 2007.Carcinoma of the rectum is a common malignancy, especially in high income countries. Local recurrence may occur after surgery alone. Preoperative radiotherapy (PRT) has the potential to reduce the risk of local recurrence and improve outcomes in rectal cancer.

OBJECTIVES

To determine the effect of preoperative radiotherapy for people with localised resectable rectal cancer compared to surgery alone.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; Issue 5, 2018) (4 June 2018), MEDLINE (Ovid) (1950 to 4 June 2018), and Embase (Ovid) (1974 to 4 June 2018). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for relevant ongoing trials (4 June 2018).

SELECTION CRITERIA

We included randomised controlled trials comparing PRT and surgery with surgery alone for people with localised advanced rectal cancer planned for radical surgery. We excluded trials that did not use contemporary radiotherapy techniques (with more than two fields to the pelvis).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the 'Risk of bias' domains for each included trial, and extracted data. For time-to-event data, we calculated the Peto odds ratio (Peto OR) and variances, and for dichotomous data we calculated risk ratios (RR) using the random-effects method. Potential sources of heterogeneity hypothesised a priori included study quality, staging, and the use of total mesorectal excision (TME) surgery.

MAIN RESULTS

We included four trials with a total of 4663 participants. All four trials reported short PRT courses, with three trials using 25 Gy in five fractions, and one trial using 20 Gy in four fractions. Only one study specifically required TME surgery for inclusion, whereas in another study 90% of participants received TME surgery.Preoperative radiotherapy probably reduces overall mortality at 4 to 12 years' follow-up (4 trials, 4663 participants; Peto OR 0.90, 95% CI 0.83 to 0.98; moderate-quality evidence). For every 1000 people who undergo surgery alone, 454 would die compared with 45 fewer (the true effect may lie between 77 fewer to 9 fewer) in the PRT group. There was some evidence from subgroup analyses that in trials using TME no or little effect of PRT on survival (P = 0.03 for the difference between subgroups).Preoperative radiotherapy may have little or no effect in reducing cause-specific mortality for rectal cancer (2 trials, 2145 participants; Peto OR 0.89, 95% CI 0.77 to 1.03; low-quality evidence).We found moderate-quality evidence that PRT reduces local recurrence (4 trials, 4663 participants; Peto OR 0.48, 95% CI 0.40 to 0.57). In absolute terms, 161 out of 1000 patients receiving surgery alone would experience local recurrence compared with 83 fewer with PRT. The results were consistent in TME and non-TME studies.There may be little or no difference in curative resection (4 trials, 4673 participants; RR 1.00, 95% CI 0.97 to 1.02; low-quality evidence) or in the need for sphincter-sparing surgery (3 trials, 4379 participants; RR 0.99, 95% CI 0.94 to 1.04; I2 = 0%; low-quality evidence) between PRT and surgery alone.Low-quality evidence suggests that PRT may increase the risk of sepsis from 13% to 16% (2 trials, 2698 participants; RR 1.25, 95% CI 1.04 to 1.52) and surgical complications from 25% to 30% (2 trials, 2698 participants; RR 1.20, 95% CI 1.01 to 1.42) compared to surgery alone.Two trials evaluated quality of life using different scales. Both studies concluded that sexual dysfunction occurred more in the PRT group. Mixed results were found for faecal incontinence, and irradiated participants tended to resume work later than non-irradiated participants between 6 and 12 months, but this effect had attenuated after 18 months (low-quality evidence).

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that PRT reduces overall mortality. Subgroup analysis did not confirm this effect in people undergoing TME surgery. We found consistent evidence that PRT reduces local recurrence. Risk of sepsis and postsurgical complications may be higher with PRT.The main limitation of the findings of the present review concerns their applicability. The included trials only assessed short-course radiotherapy and did not use chemotherapy, which is widely used in the contemporary management of rectal cancer disease. The differences between the trials regarding the criteria used to define rectal cancer, staging, radiotherapy delivered, the time between radiotherapy and surgery, and the use of adjuvant or postoperative therapy did not appear to influence the size of effect across the studies.Future trials should focus on identifying participants that are most likely to benefit from PRT especially in terms of improving local control, sphincter preservation, and overall survival while reducing acute and late toxicities (especially rectal and sexual function), as well as determining the effect of radiotherapy when chemotherapy is used and the optimal timing of surgery following radiotherapy.

Health State Utility Values for Ileostomies and Colostomies: a Systematic Review and Meta-Analysis

BACKGROUND

Ileostomies and colostomies may affect the quality of life of patients after colorectal surgery; however, the impact has been difficult to quantify using questionnaire-based measures. Utilities reflect patient preferences for health states and provide an alternate method of quality of life assessment. We aimed to systematically review the literature on utilities for ileostomy and colostomy health states.

METHODS

We searched MEDLINE, EMBASE, and EBM Reviews (to August 16, 2017) to identify studies reporting utilities for colostomies or ileostomies using direct or indirect, preference-based elicitation tools. We categorized utilities based on elicitation group (patients with stoma, patients without stoma, healthcare providers, general population) and tool. We pooled utilities using random effects models to determine mean utilities for each elicitation group and tool.

RESULTS

We identified ten studies reporting colostomy utilities and three studies reporting ileostomy utilities. Utilities were most commonly obtained using direct elicitation measures administered to individuals with an understanding of the health state. Patients with stomas and providers gave high utility ratings for the colostomy state (range 0.88-0.92 and 0.86-0.92, respectively, using direct elicitation tools). Ileostomy utilities obtained from patients following surgery and from providers also demonstrated high values placed on the ileostomy health state (range 0.88-1.0).

CONCLUSIONS

Following stoma surgery, values placed on quality of life are similar to those obtained from patients with conditions such as asthma and allergies or individuals of similar age without chronic conditions. This confirms the findings of questionnaire-based studies, which report minimal long-term decrements to overall quality of life among stomates.

Cost evaluations of radiotherapy: What do we know? An ESTRO-HERO analysis

Although economic evidence is becoming mandatory to support health care decision-making, challenges remain in generating high quality cost data, especially for complex and rapidly evolving treatment modalities, such as radiotherapy. The overall aim of this systematic literature review was to critically analyse the type and quality of radiotherapy cost information available in cost calculation studies, from the health care provider's perspective, published since 1981. A selection process, based on strict and explicit criteria, yielded 52 articles. In spite of meeting our criteria these studies displayed large heterogeneity in scope, costing method, inputs and outputs. The limited use of conventional costing methodologies along with insufficient information on resource inputs hampered comparability across studies. A consistent picture of radiotherapy costs, based on methodologically sound costing studies, has yet to emerge. These results call for developing a well-defined and generally accepted cost methodology for performing economic evaluation studies in radiotherapy.

Avoiding Radical Surgery in Elderly Patients With Rectal Cancer Is Cost-Effective

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.

Systematic review of health state utility values for economic evaluation of colorectal cancer

Cost-utility analyses undertaken to inform decision making regarding colorectal cancer (CRC) require a set of health state utility values (HSUVs) so that the time CRC patients spend in different health states can be aggregated into quality-adjusted life-years (QALY). This study reviews CRC-related HSUVs that could be used in economic evaluation and assesses their advantages and disadvantages with respect to valuation methods used and CRC clinical pathways. Fifty-seven potentially relevant studies were identified which collectively report 321 CRC-related HSUVs. HSUVs (even for similar health states) vary markedly and this adds to the uncertainty regarding estimates of cost-effectiveness. There are relatively few methodologically robust HSUVs that can be directly used in economic evaluations concerned with CRC. There is considerable scope to develop new HSUVs which improve on those currently available either by expanded collection of generic measures or by making greater use of condition-specific data, for example, using mapping algorithms.

Measuring the quality of melanoma surgery - Highlighting issues with standardization and quality assurance of care in surgical oncology

In an attempt to ensure high standards of cancer care, there is increasing interest in determining and monitoring the quality of interventions in surgical oncology. In recent years, this has been particularly the case for melanoma surgery. The vast majority of patients with melanoma undergo surgery. Usually, this is with combinations of wide excision, sentinel lymph node biopsy and lymphadenectomy. The indications for these procedures evolved during a time when no effective systemic adjuvant therapy was available, and whilst the rationale has been sound, the justification for differences in extent and thoroughness has generally been supported by inadequate or low-level evidence. This has led to a substantial variation among melanoma centres or even among surgeons within a centre in how these procedures are done. With recent rapid progress in the efficacy of systemic treatments that are impacting on overall survival, the prospect of long-term survival in these previously high risk patients means that more than ever long-term locoregional control of melanoma is imperative. Furthermore, the understanding of effects of systemic therapy on locoregional disease will only be interpretable if surgeons use standardized, high quality techniques. This article focuses on standardization and evolution of quality indicators for melanoma surgery and how these might have a positive impact on patient care.

Cost-effectiveness of palliative surgery versus nonsurgical procedures in gastrointestinal cancer patients

Palliative care is an essential component to multidisciplinary cancer care. Improved symptom control, quality of life (QOL), and survival have resulted from its utilization. Cost-effectiveness and utility analyses are significant variables that should be considered in comparing benefits and costs of medical interventions to determine if certain treatments are economically justified. This is a review on the cost-effectiveness of palliative surgery compared to other nonsurgical palliative procedures in patients with unresectable gastrointestinal cancers. J. Surg. Oncol. 2016;114:316-322. © 2016 Wiley Periodicals, Inc.

Intermediate Neoadjuvant Radiotherapy Combined With Total Mesorectal Excision for Locally Advanced Rectal Cancer: Outcomes After a Median Follow-Up of 5 Years

BACKGROUND

We previously reported the oncologic results for intermediate neoadjuvant radiotherapy (nRT) plus total mesorectal excision (TME) for locally advanced rectal cancer in a retrospective study. The objective of the present study was to further investigate the efficacy and long-term outcomes after this nRT regimen.

PATIENTS AND METHODS

From 2002 to 2011, 382 patients with resectable locally advanced rectal cancer were treated at the Peking University Cancer Hospital with 30 Gy of intermediate nRT in 10 fractions (biologic equivalent dose, 36 Gy) plus TME. Surgery, RT, and pathologic examination were standardized. The primary endpoints were local recurrence-free survival (LRFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

The median patient age at the initial treatment was 58 years (range, 22-85 years). The median patient follow-up time was 5.5 years. The estimated 5-year LRFS, CSS, and OS were 93.6%, 79.0%, and 73.6%, respectively. Of the 382 patients, 4 (1%), 4 (1%), 4 (1%), and 11 (2.9%) patients died of postoperative complications, secondary malignancies, cardiovascular and/or neurologic events, or other causes, respectively. Seven patients (1.8%) developed late-onset ileus and died after conservative treatment in peripheral hospitals.

CONCLUSION

The 10-fraction intermediate nRT regimen reported in the present study is efficient and safe. The long-term outcome is acceptable. This treatment schedule is useful as an alternative that provides efficiency, patient convenience, and low medical costs.

Prognostic value of CD45RO(+) tumor-infiltrating lymphocytes for locally advanced rectal cancer following 30 Gy/10f neoadjuvant radiotherapy

AIM

This study aims to evaluate the prognostic value of CD45RO(+) tumor-infiltrating lymphocytes (TILs) in locally advanced rectal cancer treated with 30 Gy/10 fraction (10 f) neoadjuvant radiotherapy.

METHODS

This retrospective study involved 185 patients with locally advanced rectal cancer who underwent 30 Gy/10 f nRT (biologic equivalent dose, 30 Gy) followed by total mesorectal excision (TME) between August 2003 and October 2009. The density of CD45RO(+) TILs was assessed by immunohistochemistry using an image-analysis system and tissue microarray and was evaluated for its association with histopathologic features along with disease-free survival (DFS).

RESULTS

Following neoadjuvant radiotherapy, the median density of CD45RO(+) TILs is 654/mm(2). High density of CD45RO(+) TILs was significantly associated with increased T and N downstaging effect (p = 0.006; p = 0.014), lesser-advanced T stage (p = 0.003) and TNM stage (p = 0.022). Prolonged DFS (89.0 vs. 68.1%) was also observed in CD45RO(+Hi) cases. On multivariate regression model, CD45RO(+) TILs (p = 0.026; odds ratio (OR), 0.436 (95% confidence interval (CI), 0.209-0.907)), tumor differentiation (p = 0.057; OR, 1.878 (95% CI, 0.982-3.593)), ypT stage (p = 0.066; OR, 2.383 (95% CI, 0.943-6.025)), and ypN stage (p = 0.009; OR, 2.612 (95% CI, 1.266-5.388)) were independent factors for DFS.

CONCLUSION

The density of CD45RO(+) TILs cannot only predict tumor downstaging and ypTNM stage for rectal cancer following 30 Gy/10 f nRT but also promisingly predict long-term outcomes. These findings may be used to stratify patients and make alternative strategy of adjuvant treatment.

Avoiding radical surgery improves early survival in elderly patients with rectal cancer, demonstrating complete clinical response after neoadjuvant therapy: results of a decision-analytic model

BACKGROUND

In elderly and comorbid patients with rectal cancer, radical surgery is associated with significant perioperative mortality. Data suggest that a watch-and-wait approach where a complete clinical response is obtained after neoadjuvant chemoradiotherapy might be oncologically safe.

OBJECTIVE

This study aimed to determine whether patient age and comorbidity should influence surgeon and patient decision making where a complete clinical response is obtained.

DESIGN

Decision-analytic modeling consisting of a decision tree and Markov chain simulation was used. Modeled outcome parameters were elicited both from comprehensive literature review and from a national patient outcomes database.

SETTINGS

Outcomes for 3 patient cohorts treated with neoadjuvant therapy were modeled after either surgery or watch and wait.

PATIENTS

Patients included 60-year-old and 80-year-old men with mild comorbidities (Charlson score <3) and 80-year-old men with significant comorbidities (Charlson score >3).

MAIN OUTCOME MEASURES

Absolute survival, disease-free survival, and quality-adjusted life years were measured.

RESULTS

The model found that absolute survival was similar in 60-year-old patients but was significantly improved in fit and comorbid 80-year-old patients at 1 year after treatment where watch and wait was implemented instead of radical surgery, with a survival advantage of 10.1% (95% CI, 7.9-12.6) and 13.5% (95% CI, 10.2-16.9). At all of the other time points, absolute survival was equivalent for both techniques. There were no short- or long-term differences among any patient groups managed either by radical surgery or watch and wait in terms of either disease-free survival or quality-adjusted life years.

LIMITATIONS

Oncologic data for the watch-and-wait approach used for this study is derived from only a small number of studies pertaining to a highly selected group of patients. The 90-day postoperative mortality rate derived from the United Kingdom population-based study might be lower in other countries or individual institutions.

CONCLUSIONS

This study suggests competing effects of oncologic and surgical risk when using watch-and-wait management and that elderly and comorbid patients have the most to gain from this approach.

Cost-effectiveness analysis of single fraction of stereotactic body radiation therapy compared with single fraction of external beam radiation therapy for palliation of vertebral bone metastases

PURPOSE

Stereotactic body radiation therapy (SBRT) has been proposed for the palliation of painful vertebral bone metastases because higher radiation doses may result in superior and more durable pain control. A phase III clinical trial (Radiation Therapy Oncology Group 0631) comparing single fraction SBRT with single fraction external beam radiation therapy (EBRT) in palliative treatment of painful vertebral bone metastases is now ongoing. We performed a cost-effectiveness analysis to compare these strategies.

METHODS AND MATERIALS

A Markov model, using a 1-month cycle over a lifetime horizon, was developed to compare the cost-effectiveness of SBRT (16 or 18 Gy in 1 fraction) with that of 8 Gy in 1 fraction of EBRT. Transition probabilities, quality of life utilities, and costs associated with SBRT and EBRT were captured in the model. Costs were based on Medicare reimbursement in 2014. Strategies were compared using the incremental cost-effectiveness ratio (ICER), and effectiveness was measured in quality-adjusted life years (QALYs). To account for uncertainty, 1-way, 2-way and probabilistic sensitivity analyses were performed. Strategies were evaluated with a willingness-to-pay (WTP) threshold of $100,000 per QALY gained.

RESULTS

Base case pain relief after the treatment was assumed as 20% higher in SBRT. Base case treatment costs for SBRT and EBRT were $9000 and $1087, respectively. In the base case analysis, SBRT resulted in an ICER of $124,552 per QALY gained. In 1-way sensitivity analyses, results were most sensitive to variation of the utility of unrelieved pain; the utility of relieved pain after initial treatment and median survival were also sensitive to variation. If median survival is ≥11 months, SBRT cost <$100,000 per QALY gained.

CONCLUSION

SBRT for palliation of vertebral bone metastases is not cost-effective compared with EBRT at a $100,000 per QALY gained WTP threshold. However, if median survival is ≥11 months, SBRT costs ≤$100,000 per QALY gained, suggesting that selective SBRT use in patients with longer expected survival may be the most cost-effective approach.

What is the quality of economic evaluations of non-drug therapies? A systematic review and critical appraisal of economic evaluations of radiotherapy for cancer

BACKGROUND

Breast, cervical and colorectal cancers are the three most frequent cancers in women, while lung, prostate and colorectal cancers are the most frequent in men. Much attention has been given to the economic evaluation of pharmaceuticals for treatment of cancer by the National Institute for Health and Care Excellence (NICE) in the UK and similar authorities internationally, while economic analysis developed for other types of anti-cancer interventions, including radiotherapy and surgery, are less common.

OBJECTIVES

Our objective was to review methods used in published cost-effectiveness studies evaluating radiotherapy for breast, cervical, colorectal, head and neck and prostate cancer, and to compare the economic evaluation methods applied with those defined in the guidelines used by the NICE technology appraisal programme.

METHODS

A systematic search of seven databases (MEDLINE, EMBASE, CDSR, NHSEED, HTA, DARE, EconLit) as well as research registers, the NICE website and conference proceedings was conducted in July 2012. Only economic evaluations of radiotherapy interventions in individuals diagnosed with cancer that included quality-adjusted life-years (QALYs) or life-years (LYs) were included. Included studies were appraised on the basis of satisfying essential, preferred and UK-specific methods requirements, building on the NICE Reference Case for economic evaluations and on other methods guidelines.

RESULTS

A total of 29 studies satisfied the inclusion criteria (breast 14, colorectal 2, prostate 10, cervical 0, head and neck 3). Only two studies were conducted in the UK (13 in the USA). Among essential methods criteria, the main issue was that only three (10%) of the studies used clinical-effectiveness estimates identified through systematic review of the literature. Similarly, only eight (28%) studies sourced health-related quality-of-life data directly from patients with the condition of interest. Other essential criteria (e.g. clear description of comparators, patient group indication and appropriate time horizon) were generally fulfilled, while most of the UK-specific requirements were not met.

CONCLUSION

Based on this review there is a dearth of up-to-date, robust evidence on the cost effectiveness of radiotherapy in cancer suitable to support decision making in the UK. Studies selected did not fully satisfy essential method standards currently recommended by NICE.

Patient-reported outcomes and survivorship in radiation oncology: overcoming the cons

PURPOSE

Although patient-reported outcomes (PROs) have become a key component of clinical oncology trials, many challenges exist regarding their optimal application. The goal of this article is to methodically review these barriers and suggest strategies to overcome them. This review will primarily focus on radiation oncology examples, will address issues regarding the "why, how, and what" of PROs, and will provide strategies for difficult problems such as methods for reducing missing data. This review will also address cancer survivorship because it closely relates to PROs.

METHODS

Key articles focusing on PROs, quality of life, and survivorship issues in oncology trials are highlighted, with an emphasis on radiation oncology clinical trials. Publications and Web sites of various governmental and regulatory agencies are also reviewed.

RESULTS

The study of PROs in clinical oncology trials has become well established. There are guidelines provided by organizations such as the US Food and Drug Administration that clearly indicate the importance of and methodology for studying PROs. Clinical trials in oncology have repeatedly demonstrated the value of studying PROs and suggested ways to overcome some of the key challenges. The Radiation Therapy Oncology Group (RTOG) has led some of these efforts, and their contributions are highlighted. The current state of cancer survivorship guidelines is also discussed.

CONCLUSION

The study of PROs presents significant benefits in understanding and treating toxicities and enhancing quality of life; however, challenges remain. Strategies are presented to overcome these hurdles, which will ultimately improve cancer survivorship.

A Review and Meta-analysis of Colorectal Cancer Utilities

OBJECTIVE

To perform a systematic review of utility weights for colorectal cancer (CRC) health states reported in the scientific literature and to determine the effects of disease factors, patient characteristics, and utility methods on utility values.

METHODS

We identified 26 articles written in English and published from January 1980 to January 2013, providing 351 unique utilities for CRC health states elicited from 6546 unique respondents. The CRC utility data were analyzed using linear mixed-effects models with CRC type, stage, time to or from initial care, utility measurement instrument, and administration method as independent variables.

RESULTS

In the base case model, the estimated utility for a patient with stage I to III CRC more than 1 year after surgery, rated using a self-administered time tradeoff instrument, was 0.90. Stage, time to or from initial care, and utility measurement instrument were associated with statistically significant utility differences ranging from -0.19 to 0.02. Utilities for patients with stage IV cancer were 0.19 lower (P < 0.001) than for those with stage I to III cancer. Utilities elicited at more than 1 year after surgery were 0.05 higher than those elicited at 3 months after surgery (P = 0.008). Estimates of differences between utility measurement instruments were sensitive to how repeated scores in the same patient group were treated, and other findings were sensitive to how the disease stage was modeled and method of administration.

CONCLUSIONS

Variations in reported utilities are associated with factors such as cancer stage, time to or from initial care, and utility measurement instrument. More research is needed to study why apparently similar patients report different quality of life.

Tafazzin protein expression is associated with tumorigenesis and radiation response in rectal cancer: a study of Swedish clinical trial on preoperative radiotherapy

BACKGROUND

Tafazzin (TAZ), a transmembrane protein contributes in mitochondrial structural and functional modifications through cardiolipin remodeling. TAZ mutations are associated with several diseases, but studies on the role of TAZ protein in carcinogenesis and radiotherapy (RT) response is lacking. Therefore we investigated the TAZ expression in rectal cancer, and its correlation with RT, clinicopathological and biological variables in the patients participating in a clinical trial of preoperative RT.

METHODS

140 rectal cancer patients were included in this study, of which 65 received RT before surgery and the rest underwent surgery alone. TAZ expression was determined by immunohistochemistry in primary cancer, distant, adjacent normal mucosa and lymph node metastasis. In-silico protein-protein interaction analysis was performed to study the predictive functional interaction of TAZ with other oncoproteins.

RESULTS

TAZ showed stronger expression in primary cancer and lymph node metastasis compared to distant or adjacent normal mucosa in both non-RT and RT patients. Strong TAZ expression was significantly higher in stages I-III and non-mucinious cancer of non-RT patients. In RT patients, strong TAZ expression in biopsy was related to distant recurrence, independent of gender, age, stages and grade (p = 0.043, HR, 6.160, 95% CI, 1.063-35.704). In silico protein-protein interaction study demonstrated that TAZ was positively related to oncoproteins, Livin, MAC30 and FXYD-3.

CONCLUSIONS

Strong expression of TAZ protein seems to be related to rectal cancer development and RT response, it can be a predictive biomarker of distant recurrence in patients with preoperative RT.

Can a biomarker-based scoring system predict pathologic complete response after preoperative chemoradiotherapy for rectal cancer?

BACKGROUND

Numerous molecular markers have been investigated as potential predictors of tumor responses to preoperative chemoradiotherapy (preCRT) for rectal cancer.

OBJECTIVE

To develop a system in which biomarkers are used to predict the likelihood of a pathologic complete response (pCR) to preCRT.

DESIGN & SETTING

This is a retrospective analysis of tumor specimens collected prior to preCRT from 81 patients who underwent curative resection for primary rectal adenocarcinoma between June 2008 and February 2012.

MAIN OUTCOME MEASURES

Using tissue microarrays and immunohistochemistry, expression levels of twelve candidate biomarkers (p53, p21, Bcl2, Bax, EGFR, Cox-2, MLH-1, MSH-2, Ku70, VEGF, TS, Ki-67) were evaluated in paraffin-embedded tumor samples collected before preCRT. The correlation between biomarker expression levels and the pathologic response to preCRT was assessed based on histopathological staging (pTNM) and tumor regression grade (TRG).

RESULTS

Expression levels of 4 biomarkers (p53, VEGF, p21, Ki67) correlated with pCR. Patients showing low expression of p53 and/or high expression of VEGF, p21, and Ki67 exhibited a significantly greater pCR rate. A scoring system devised so that one point was given for each biomarker whose expression level correlated with pCR (score range: 0-4) showed that 1 of 26 patients with scores of 0 to 1 achieved pCR, whereas 26 of 55 patients with scores of 2 to 4 achieved pCR (3.8% vs. 47.3%, p < 0.001). For prediction of pCR, the scoring system showed 96.3% sensitivity, 46.3% specificity, a 47.3% positive predictive value, and a 96.2% negative predictive value.

LIMITATIONS

Immunohistochemistry has limitations related to reproducibility and the ability to provide quantitative information. In addition, this study lacks test and validation sets.

CONCLUSIONS

Expression levels of 4 biomarkers correlated with pCR after preCRT for rectal cancer. A scoring system based on levels of biomarker expression showed good sensitivity and negative predictive value for pCR.

Prognostic value of pretreatment level of carcinoembryonic antigen on tumour downstaging and early occurring metastasis in locally advanced rectal cancer following neoadjuvant radiotherapy (30 Gy in 10 fractions)

AIM

To evaluate the role of carcinoembryonic antigen (CEA) in predicting the response to and prognosis for locally advanced rectal cancer treated with 30 Gy neoadjuvant radiotherapy (nRT) in 10 fractions (30 Gy/10 f).

METHOD

This retrospective study involved 240 patients with locally advanced rectal cancer who underwent 30 Gy/10 f nRT (biologically equivalent dose 36 Gy) followed by total mesorectal excision between August 2003 and 2009. Serum CEA level was determined before administration of nRT. The prognostic value of serum CEA level on tumour downstaging and 3-year disease-free survival was analysed.

RESULTS

Ninety out of 240 (37.5%) patients had elevated CEA levels before nRT. The incidence of T downstaging in patients decreased significantly as the pretreatment CEA levels became more elevated (< 5 ng/ml, 50.7%; 5-10 ng/ml, 39.5%; > 10 ng/ml, 17.3%; P = 0.00014). Downstaging to ypCR or ypStage I occurred in 46.7% (66/150) of patients with a CEA level of < 5 ng/ml and 34.2% (13/38) of patients with a CEA level of 5-10 ng/ml. In contrast, just 13.5% (7/52) of those with a CEA level > 10 ng/ml downstaged to ypStage I and none of them achieved ypCR, with statistical difference (P = 0.001). A significantly higher incidence of early metastasis (within 6 postoperative months) was observed with increasing CEA level: 2.0% (3/150), 5.4% (2/38) and 11.5% (6/52) in patients with CEA level < 5 ng/ml, 5-10 ng/ml or > 10 ng/ml, respectively (P = 0.018).

CONCLUSION

Pretreatment CEA level cannot only predict tumour downstaging and ypTNM stage for rectal cancer following 30 Gy/10 f nRT, but also promisingly suggests a high incidence of early occurring distant metastasis. These findings may be used to select patients with nRT resistance and occult metastasis and make alternative treatment strategies.

Livin expression is an independent factor in rectal cancer patients with or without preoperative radiotherapy

BACKGROUND

This study was aimed to investigate the expression significance of Livin in relation to radiotherapy (RT), clinicopathological and biological factors of rectal cancer patients.

METHODS

This study included 144 primary rectal cancer patients who participated in a Swedish clinical trial of preoperative radiotherapy. Tissue microarray samples from the excised primary rectal cancers, normal mucosa and lymph node metastases were immunostained with Livin antibody. The proliferation of colon cancer cell lines SW620 and RKO was assayed after Livin knock-down.

RESULTS

The expression of Livin was significantly increased from adjacent (P = 0.051) or distant (P = 0.028) normal mucosa to primary tumors. 15.4% (2/13) and 39.7% (52/131) patients with Livin-negative and positive tumors died at 180 months after surgery, and the difference tended to be statistically significant (P = 0.091). In multivariate analyses, the difference achieved statistical significance, independent of TNM stage, local and distant recurrence, grade of differentiation, gender, and age (odds ratio = 5.09, 95% CI: 1.01-25.64, P = 0.048). The in vitro study indicated colon cancer cells with Livin knock-down exhibited decreased proliferation compared with controls after RT.

CONCLUSIONS

The expression of Livin was was independently related to survival in rectal cancer patients, suggesting Livin as a useful prognostic factor for rectal cancer patients.

The management of patients with T1 adenocarcinoma of the low rectum: a decision analysis

BACKGROUND

Decision making for patients with T1 adenocarcinoma of the low rectum, when treatment options are limited to a transanal local excision or abdominoperineal resection, is challenging.

OBJECTIVES

The aim of this study was to develop a contemporary decision analysis to assist patients and clinicians in balancing the goals of maximizing life expectancy and quality of life in this situation.

DESIGN

We constructed a Markov-type microsimulation in open-source software. Recurrence rates and quality-of-life parameters were elicited by systematic literature reviews. Sensitivity analyses were performed on key model parameters.

PATIENTS AND SETTING

Our base case for analysis was a 65-year-old man with low-lying T1N0 rectal cancer. We determined the sensitivity of our model for sex, age up to 80, and T stage.

MAIN OUTCOME MEASURES

The main outcome measured was quality-adjusted life-years.

RESULTS

In the base case, selecting transanal local excision over abdominoperineal resection resulted in a loss of 0.53 years of life expectancy but a gain of 0.97 quality-adjusted life-years. One-way sensitivity analysis demonstrated a health state utility value threshold for permanent colostomy of 0.93. This value ranged from 0.88 to 1.0 based on tumor recurrence risk. There were no other model sensitivities.

LIMITATIONS

Some model parameter estimates were based on weak data.

CONCLUSIONS

In our model, transanal local excision was found to be the preferable approach for most patients. An abdominoperineal resection has a 3.5% longer life expectancy, but this advantage is lost when the quality-of-life reduction reported by stoma patients is weighed in. The minority group in whom abdominoperineal resection is preferred are those who are unwilling to sacrifice 7% of their life expectancy to avoid a permanent stoma. This is estimated to be approximately 25% of all patients. The threshold increases to 12% of life expectancy in high-risk tumors. No other factors are found to be relevant to the decision.

Colorectal cancer: current care, future innovations and economic considerations

For those involved in colorectal cancer management, the present day is an exciting time. There is a multitude of new techniques to be considered for early detection (screening). National population screening for 60-69-year olds in England is due to start this year. Also, minimally invasive surgical techniques and multimodal pathways of care are aiding faster recovery, and there are increasing options for both adjuvant and palliative therapies. This article summarizes how colorectal cancer is currently managed in the UK and discusses the developments that are in the early stages of clinical use or on the horizon. Current management is discussed in detail in the hope that innovators reading the article may identify areas for improvement and allow comparison of new interventions with what are currently the gold standards. As changes are moving so fast, this review will probably only relate to the next 10 years at most. It does not provide a detailed reference list to support all therapies but indicates the key publications that will enable more detailed reading.

Cost-effectiveness of oxaliplatin in the adjuvant treatment of colon cancer in Canada

Objective

The cost-effectiveness of oxaliplatin in combination with 5-fluorouracil/leucovorin (5fu/lv)—the folfox regimen—was compared with that of 5fu/lv alone as adjuvant therapy for patients with stage iii colon cancer, from the perspective of the Cancer Care Ontario New Drug Funding Program. In the mosaic (Multicenter International Study of Oxaliplatin/5-Fluorouracil/Leucovorin in the Adjuvant Treatment of Colon Cancer) trial, the folfox regimen significantly improved disease-free survival. The mosaic trial formed the basis of the present analysis.

Methodology

Extrapolated patient-level data from the mosaic trial were used to model patient outcomes from treatment until death. Utilities were obtained from the literature. Resource utilization data were derived from the mosaic trial and supplemented with data from the literature. Unit costs were obtained from the Ontario Ministry of Health and Long-Term Care, the London Health Sciences Centre, and the literature.

Results

Lifetime incremental cost-effectiveness ratios for folfox compared with 5fu/lv were CA$14,266 per disease-free year, CA$23,598 per life-year saved, and CA$24,104 per quality adjusted life-year (qaly) gained, discounting costs and outcomes at 5% per annum. These results were stable for a wide range of inputs; only utility values associated with relapse seemed to influence the cost-effectiveness ratios observed.

Conclusions

With an incremental cost of CA$24,104 per qaly gained, folfox is a cost-effective adjuvant treatment for stage iii colon cancer. Compared with 5fu/lv alone, this regimen offers better clinical outcomes and provides good value for money.

Cost-effectiveness studies in radiation therapy

The field of radiation therapy has made dramatic technical advances over the past 20 years. 3D conformal radiotherapy, intensity-modulated radiation therapy and proton beam therapy have all been developed in an attempt to improve the therapeutic ratio: higher cure rates with lower toxicity. Unfortunately, although the costs of radiation therapy are certainly increasing, it is unclear whether its clinical benefit has also improved. Cost-effectiveness analyses are designed to formally evaluate the cost of a treatment relative to an associated change in quality-adjusted survival. As the cost of oncologic care is increasing, it is critically important to assess the cost-effectiveness of radiation therapy. This article will describe the issues surrounding the delivery and cost of radiation therapy, and it will summarize the work that has been done to evaluate the use of cost-effectiveness in radiation oncology.

Physical performance and quality of life after extended abdominoperineal excision of rectum and reconstruction of the pelvic floor with gluteus maximus flap

PURPOSE

This study aimed to evaluate the physical performance and quality of life after an extended abdominoperineal excision of the rectum and the reconstruction with a right-sided unilateral gluteus myocutaneus rotation flap in patients with rectal and anal cancer.

METHOD

Nineteen patients with primary or recurrent rectal or anal cancer were investigated a mean of 26 months (range, 10-39 mo) after the operation. All patients received preoperative radiation therapy. Physical performance, hip movability, balance, and ability to sit were measured according to a prospective protocol, and the patients' perception of pain and quality of life were investigated with questionnaires. Postoperative complications and oncological results were registered retrospectively from patient records of 36 patients who had undergone operations.

RESULTS

The timed-stands test showed that 12 of 19 patients performed worse than the upper limit of reference values adjusted for age and gender. The Berg balance scale showed a mean score of 52.8 that is close to the maximum score (56) of the test. The mean calculated EQ-5D (EuroQol Group, Rotterdam, The Netherlands) quality-of-life index was 0.71 based on the 5 questions in the instrument. The ability to sit 10 minutes was reduced in 4 patients, and 8 patients used a cushion or ring. Mean pain score was 20 (visual analog scale from 0 to 100) while sitting, and only 9 of 19 patients were pain free. The hip mobility was normal, but 6 patients had reduced flexion strength on the right side compared with the left side. Twenty-eight of 36 patients (78%) had some kind of early or late complication after surgery. Local recurrence was found in 4 of 36 patients (11%).

CONCLUSION

The oncological outcome of the operation was acceptable, but functional drawbacks must be considered preoperatively in counseling the patient. More research is needed to find ways to preserve better function and well-being.

Preoperative chemoradiation vs radiation alone for stage II and III resectable rectal cancer: a meta-analysis

AIM

The aim of this systematic literature review and meta-analysis was to compare preoperative radiotherapy (RT) with preoperative chemoradiotherapy (ChRT) in patients with stage II and III resectable rectal cancer.

METHOD

A comprehensive PubMed, Cohrane and Ovid electronic database search was performed. Articles published during the period 1960-2007 were included. The analysis included only randomized controlled trials, where patients with stage II and III resectable rectal cancer were randomized to one of at least two schedules of preoperative therapy including RT or ChRT followed by surgery. Secondary estimates for the experimental ChRT group were calculated and compared with the estimates pooled from trials which included short-course radiotherapy (SRT).

RESULTS

We identified 1017 articles including 242 clinical trials, 65 of which were randomized studies. Five trials from these randomized studies compared preoperative RT with conventional ChRT and only one included a group having SRT. The complete response rate was significantly better after preoperative chemoradiation compared with preoperative RT alone but the rate of toxicity was higher. Theoretically higher curative resection rates with less morbidity were found after ChRT compared with preoperative SRT.

CONCLUSION

Preoperative ChRT for patients with stage II and III resectable rectal cancer gives better complete response rates compared with RT alone but it also results in higher toxicity.

Increased spontaneous apoptosis, but not survivin expression, is associated with histomorphologic response to neoadjuvant chemoradiation in rectal cancer

PURPOSE

Survivin has been shown to be an important mediator of cellular radioresistance in vitro. This study aims to compare survivin expression and apoptosis to histomorphologic responses to neoadjuvant radiochemotherapy (RCT) in rectal cancer.

MATERIALS AND METHODS

Thirty-six pre-treatment biopsies were studied. Survivin mRNA and protein expression plus TUNEL staining for apoptosis was performed. Response to treatment was assessed using a 5-point tumour regression grade.

RESULTS

Survivin expression was not found to be predictive of response to RCT (p = NS). In contrast, spontaneous apoptosis was significantly (p = 0.0051) associated with subsequent response to RCT. However, no association between survivin expression and levels of apoptosis could be identified.

CONCLUSIONS

This in vivo study failed to support in vitro studies showing an association between survivin and response to chemotherapy and radiation therapy. These results caution against the translation of the in vitro properties of survivin into a clinical setting.

pRb2/p130 protein in relation to clinicopathological and biological variables in rectal cancers with a clinical trial of preoperative radiotherapy

BACKGROUND

pRb2/p130 plays a key role in cell proliferation and is a considerable progress about expression patterns of pRb2/p130 in number of malignancies. However, pRb2/p130 expression and its significance in rectal cancer remain unknown. The purpose of the present study was to investigate pRb2/p130 protein patterns and their correlations with clinicopathological and biological factors in rectal cancer patients with or without preoperative radiotherapy (RT).

PATIENT/METHODS

pRb2/p130 protein was examined by immunohistochemistry in 130 primary tumors, along with the corresponding 61 distant normal mucosa specimens, 85 adjacent normal mucosa specimens, 34 lymph node metastases, and 93 primary tumor biopsies from rectal cancer patients who participated in a Swedish clinical trial of preoperative RT.

RESULTS

The pRb2/p130 protein was mainly localized in the cytoplasm of tumor cells. In nonradiated cases, the lack of pRb2/p130 was related to advanced tumor-node-metastases stage, poorer differentiation, weak fibrosis, less inflammatory infiltration, higher Ki-67, and positive Cox-2 expression (p < 0.05). In radiated cases, the lack of pRb2/p130 was related to nonstaining of Cox-2 and survivin (p < 0.05). pRb2/p130 protein in primary tumors tended to be increased after RT (27% vs 16%, p = 0.07).

CONCLUSION

pRb2/p130 was mainly localized in the cytoplasm rather than in the nucleus in rectal cancer. After RT, pRb2/p130 protein seems to be increased in primary tumors, and further the relationship of the pRb2/p130 with the clinicopathological and biological variables changed compared to the nonradiated cases. However, we did not find that the pRb2/p130 was directly related to RT, tumor recurrence, and patients' survival.

Preliminary validation of an optimally weighted patient-based utility index by application to randomized trials in breast cancer

OBJECTIVES

To optimize, apply, and validate a scoring algorithm that provides a utility index from a cancer-specific quality of life questionnaire called the Utility-Based Questionnaire-Cancer (UBQ-C) using data sets from randomized trials in breast cancer. The index is designed to reflect the perspective of cancer patients in a specific clinical context so as to best inform clinical decisions.

METHODS

We applied the UBQ-C scoring algorithm to trials of chemotherapy for advanced (n = 325) and early (n = 126) breast cancer. The algorithm converts UBQ-C subscales into a subset index, and combines it with a global health status item into an overall HRQL index, which is then converted to a utility index using a power transformation. The optimal subscale weights were determined by their correlations with the global scale in the relevant data set. The validity of the utility index was tested against other patient characteristics.

RESULTS

Optimal weights (range 0-1) for the subset index in advanced (early) breast cancer were: physical function 0.20 (0.09); social/usual activities 0.23 (0.25); self-care 0.04 (0.01); and distresses 0.53 (0.64). Weights for the overall HRQL index were health status 0.66 (0.63) and subset index 0.34 (0.37). The utility index discriminated between breast cancer that was advanced rather than early (means 0.88 vs. 0.94, P < 0.0001) and was responsive to the toxic effects of chemotherapy in early breast cancer (mean change 0.07, P < 0.0001).

CONCLUSIONS

The scoring algorithm for the UBQ-C utility index can be optimized in different clinical contexts to reflect the relative importance of different aspects of quality of life to the patients in a trial. It can be used to generate sensitive and responsive utility scores, and quality-adjusted life-years that can be used within a trial to compare the net benefit of treatments and inform clinical decision-making.

Deriving a patient-based utility index from a cancer-specific quality of life questionnaire

OBJECTIVES

The aim of this study was to derive a scoring algorithm for a validated disease-specific quality of life instrument called the Utility-Based Questionnaire-Cancer (UBQ-C) that provided a utility index designed to inform clinical decisions about cancer treatments.

METHODS

The UBQ-C includes a scale for global health status (1 item); and subscales for physical function (3 items), social/usual activities (4 items), self-care (1 item), and distresses because of physical and psychological symptoms (21 items). A scoring algorithm was derived to convert the subscales into a subset index, and combine it with the global scale into an overall health-related quality of life (HRQL) index, which was converted to a utility index with a power transformation. The valuation survey consisted of 204 advanced cancer patients who completed the UBQ-C and assigned time trade-off (TTO) utilities about their own health state. Preliminary validation involved comparing these derived utilities with other measures of HRQL.

RESULTS

Weights for the subset index were: physical function 0.28, social/usual activities 0.06, self-care 0.01, and distresses 0.64. Weights for the overall HRQL index were health status 0.65 and subset index 0.35. The mean of the utility index scores was similar to the mean of the TTO utilities (0.92 vs. 0.91, P = 0.6). The utility index was substantially correlated with other measures of HRQL.

CONCLUSIONS

Data from a simple, self-rated, disease-specific questionnaire can be converted into a utility index suitable for comparing the net effect of cancer treatments on quality of life, and to evaluate trade-offs between quality and quantity of life in quality-adjusted survival analyses.

Treatment for patients with rectal cancer and a clinical complete response to neoadjuvant therapy: a decision analysis

PURPOSE

A clinical complete response to neoadjuvant therapy occurs in a subset of patients with rectal cancer. Management of these patients is controversial and tension exists between the recurrence risk with observation, and the impact of surgery on quality-of-life. Therefore, the objective was to develop a decision-analytic model to evaluate the relative benefits of surgery vs. observation in rectal cancer patients who achieve clinical complete response after neoadjuvant chemoradiation.

METHODS

Clinically relevant inputs and events, including the ability to identify complete responders, likelihood of relapse and of salvage surgery after relapse, and utilities for each health state, were simulated by use of a Markov state-transition model. Transition probabilities and health-state utilities were derived from the literature and expert consensus. One-way and two-way sensitivity analyses were performed to assess the robustness of model results to assumptions. The primary outcome was quality-adjusted life expectancy.

RESULTS

In the base-case analysis, the quality-adjusted life expectancy with surgery exceeded observation (5.63 vs. 5.34 quality-adjusted life-years). Sensitivity analysis demonstrated that observation was preferred to surgery if the ability to correctly identify patients with true complete responses exceeded 58 percent, if quality-of-life after surgery was poor (utility <0.81), or if the relative reduction in recurrence risk with surgery was <43 percent when compared with observation.

CONCLUSIONS

Our model outlines the issues associated with surgery vs. observation, and suggests that surgery is beneficial for the average patient with rectal cancer with a clinical complete response after neoadjuvant therapy. Current limitations in the clinical assessment of patient response to chemoradiation constitute an important factor influencing our results, and therefore warrant further investigation.