Neoadjuvant Treatment Versus Upfront Surgery in Resectable Pancreatic Cancer: A Cost-Effectiveness Analysis

Cost of Neoadjuvant Immunotherapy vs Up-Front Surgery in Cutaneous Squamous Cell Carcinoma: A Post Hoc Analysis of a Nonrandomized Clinical Trial

Importance

There is increasing interest in use of neoadjuvant immunotherapy (NAT) in advanced cutaneous squamous cell carcinoma (cSCC) to reduce surgical morbidity and forego adjuvant therapy, while potentially improving survival outcomes.

Objective

To assess the cost to Medicare of NAT compared with up-front surgery.

Design, Setting, and Participants

This cohort study was a post hoc analysis of a phase 2 clinical trial evaluating the feasibility of neoadjuvant atezolizumab. The study was conducted from June 2021 to December 2023 at a tertiary-level academic institution among 20 patients with advanced stage II-IV cSCC.

Interventions

Up to 3 doses of neoadjuvant atezolizumab, followed by surgical resection with or without adjuvant radiation therapy.

Main Outcomes and Measures

Direct medical costs in US dollars of care received on trial were compared with baseline treatment plans of up-front surgery developed a priori from a Medicare payer perspective.

Results

Of 20 patients with advanced cSCC enrolled (median [range] age, 71.5 [53-88] years; 17 male [85.0%]), most individuals had stage III (12 patients [60.0%]) or IV (5 patients [25.0%]) disease. The median (range) follow-up was 14.2 (3.5-28.7) months. Compared with $26 602.67 for up-front surgery, NAT was associated with mean overall costs of $51 561.02, or a 93.8% increase, equivalent to $24 958.36 (95% CI, $22 057.95 to $24 692.43) per patient, which was primarily associated with the drug acquisition costs of atezolizumab ($30 603.96). NAT was associated with mean cost reductions from $12 707.07 to $10 543.71 (17.0%) in surgery and $11 711.97 to $7157.32 (38.9%) in radiation across all patients compared with up-front surgery. Adjuvant radiation therapy was obviated in 5 of 17 patients not previously irradiated (29.4%), reducing costs of radiation. Mean (SD) surgical complexity was reduced from 63.81 (30.55) to 44.71 (32.49) work relative value units (wRVUs; difference, 19.10 wRVU; 95% CI, 5.00 to 33.20 wRVU). NAT was associated with 5 fewer free flaps, 4 fewer neck dissections, 5 more organ-preserving resections, and 3 conversions from inpatient to outpatient surgery.

Conclusions and Relevance

This study found that treatment with 3 doses of NAT was associated with an overall cost increase compared with up-front surgery, driven by drug acquisition costs, and cost reductions from less extensive surgical resections and obviated adjuvant radiation. Predictive markers for response to NAT could optimize patient selection and improve cost-effectiveness.

Trial Registration

ClinicalTrials.gov Identifier: NCT04710498.

Locally Advanced Gastric Cancer Management: A Cost-Effectiveness Analysis

Across the nation, patients with locally advanced gastric cancer (LAGC) are managed with modalities including upfront surgery (US) and perioperative chemotherapy (PCT). Preoperative therapies have demonstrated survival benefits over US and thus long-term outcomes are expected to vary between the options. However, as these 2 modalities continue to be regularly employed, we sought to perform a decision analysis comparing the costs and quality-of-life associated with the treatment of patients with LAGC to identify the most cost-effective option. We designed a decision tree model to investigate the survival and costs associated with the most commonly utilized management modalities for LAGC in the United States: US and PCT. The tree described costs and treatment strategies over a 6-month time horizon. Costs were derived from 2022 Medicare reimbursement rates using the third-party payer perspective for physicians and hospitals. Effectiveness was represented using quality-adjusted life-years (QALYs). One-way, two-way, and probabilistic sensitivity analyses were utilized to test the robustness of our findings. PCT was the most cost-effective treatment modality for patients with LAGC over US with a cost of $40,792.16 yielding 3.11 QALYs. US has a cost of $55,575.57 while yielding 3.15 QALYs; the incremental cost-effectiveness ratio (ICER) was $369,585.25. One-way and two-way sensitivity analyses favored PCT in all variations of variables across their standard deviations. Across 100,000 Monte Carlo simulations, 100% of trials favored PCT. In our model simulating patients with LAGC, the most cost-effective treatment strategy was PCT. While US demonstrated improved QALYs over PCT, the associated cost was too great to justify its use.

Treatment Costs and Social Burden of Pancreatic Cancer

(1) Background: Pancreatic cancer is the cancer with the third-highest mortality rate, and forecasts indicate its growing share in morbidity. The basis of treatment is inpatient chemotherapy and there is a strong focus on palliative care. (2) Methods: A literature review was conducted based on the rapid review methodology in PubMed and Cochrane databases. The search was supplemented with publications from the snowball search. Qualitative assessment of included publications was performed using AMSTAR2 modified scheme. (3) Results: The review included 17 publications, of which majority concerned direct costs related to the adopted treatment regimen. Most of the publications focused on comparing the cost-effectiveness of drug therapies and the costs of palliative treatment. Other publications concerned indirect costs generated by pancreatic cancer. They particularly focused on the economic burden of lost productivity due to sickness absence. (4) Conclusion: The increase in the incidence of pancreatic cancer translates into an increase in the costs of the health care system and indirect costs. Due to the significant share of hospitalization in the health care structure, direct costs are increasing. The inpatient treatment regimen and side effects translate into a loss of productivity for patients with pancreatic cancer. Among gastrointestinal cancers, pancreatic cancer generates the second largest indirect costs, although it has a much lower incidence rate than the dominant colorectal cancer. This indicates a significant problem of the economic burden of this cancer.