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

PurposeThis work describes the methodology adopted and the results obtained in a utility elicitation task. The purpose was to elicit utility coefficients (UCs) needed to calculate quality-adjusted life years for a cost/utility analysis of TORS (Trans-Oral robotic Surgery) versus TLM (Trans-oral Laser Microsurgery), which are two minimally-invasive trans-oral surgery techniques for head & neck cancers.MethodsSince the economic evaluation would be conducted from the point of view of the Swiss healthcare system, Swiss people (healthy volunteers) have been interviewed in order to tailor the model to that specific country. The utility elicitation was performed using a computerized tool (UceWeb). Standard gamble and rating scale methods were used.ResultsUCs have been elicited from 47 individuals, each one providing values for 18 health states, for a total of 1692 expected values. Health states, described using graphical factsheets, ranged from remission to palliative care. Elicited UCs were different among states, ranging from 0.980 to 0.213. Those values were comparable to previously published results from a Canadian population, except for states related to recurrent disease (local, regional, and distant), and palliation, where the Swiss population showed lower utility values.ConclusionFrom a methodological point of view, our study shows that the UceWeb tool can be profitably used for utility elicitation from healthy volunteers. From an application point of view, the study provides utility values that can be used not only for a specific cost-utility analysis, but for future studies involving health states following trans-oral head & neck surgery. Moreover, the study confirms that some UCs vary among countries, demanding for tailored elicitation tasks.

Purpose The purpose of this study was to assess utility coefficients of health states following two minimally invasive surgical approaches for head and neck cancer, namely trans-oral robotic surgery and trans-oral laser microsurgery. Those utility coefficients will be later exploited in an economic evaluation study comparing the two approaches. Methods The above cited economic evaluation will be done from the Swiss healthcare system perspective and, as such, Swiss healthcare professionals were interviewed to elicit utility coefficients. Health states, ranging from remission to palliative care, were described using clinical vignettes. A computerized tool (UceWeb) implementing standard gamble and rating scale methods was used. Results Utility coefficients for 18 different health states were elicited with the two methods from 47 individuals, for a total of 1692 values. Elicited values varied from 0.980 to 0.213. Comparison with values elicited in previous studies show the need for population-specific elicitation, mainly for the worst health states. Conclusion Herein we report health utility coefficients for the Swiss population for health states following minimally invasive trans-oral surgery. This study provides utility values that can be used not only for a specific cost-utility analysis, but also for future studies involving the same health states.

ImportanceTransoral robotic surgery (TORS) and transoral laser micro-surgery (TLM) are two different but competing minimally invasive techniques to surgically remove operable oropharyngeal squamous cell cancers (OPSCC). As of now, no comparative analysis as to the cost-utility of these techniques exists.ObjectiveRecent population-level data suggest for TORS and TLM equivalent tumor control, but different total costs, need for adjuvant chemoradiation, and learning curves. Therefore, the objective of this study was to compare TORS and TLM from the cost-utility (C/U) point of view using a decision-analytical model from a Swiss hospital perspective.DesignOur decision-analytical model combines decision trees and a Markov model to compare TORS and TLM strategies. Model parameters were quantified using available literature, original cost data from two Swiss university tertiary referral centers, and utilities elicited directly from a Swiss population sample using standard gamble. C/U and sensitivity analyses were used to generate results and gauge model robustness.SettingSwiss hospital perspectiveInterventionCost-utility analysisMain outcome measureComparative cost-utility data from TLM and TORSResultsIn the base case analysis TLM dominates TORS. This advantage remains robust, even if the costs for TORS would reduce by up to 25%. TORS begins to dominate TLM, if less than 59,7% patients require adjuvant treatment (pTorsAlone>0.407), whereby in an interval between 55%-62% (pTorsAlone 0.38-0.45) cost effectiveness of TORS is sensitive to the prescription of adjuvant CRT. Also, exceeding 29% of TLM patients requiring a re-operation for inadequate margins renders TORS more cost-effective.ConclusionTLM is more cost-effective than TORS. However, this advantage is sensitive to various parameters i.e. the number of re-operations and adjuvant treatment.Key pointsQuestionCompare cost-utility of TORS versus TLMFindingsIn the base case analysis TLM dominates TORS, even if the costs for TORS would reduce by up to 25%. TORS begins to dominate TLM, if less than 59,7% patients require adjuvant treatment, whereby in an interval between 55%-62% cost effectiveness of TORS is sensitive to the prescription of adjuvant CRT. Exceeding 29% of TLM patients requiring a re-operation for inadequate margins renders TORS more cost-effective.MeaningTLM is more cost-effective than TORS. However, this advantage is sensitive to the number of re-operations and adjuvant treatment