Cost-Effectiveness Analysis of Total Neoadjuvant Therapy Followed by Radical Resection Versus Conventional Therapy for Locally Advanced Rectal Cancer

Abstract

BACKGROUND: Definitive surgery with total mesorectal excision is the mainstay of treatment for locally advanced rectal cancer. Multimodality therapy improves long-term survival. Current standards advise neoadjuvant chemoradiation followed by radical surgery and adjuvant chemotherapy. Nationally, compliance with adjuvant chemotherapy is only 32%. New research evaluates the effectiveness of total neoadjuvant therapy: complete chemotherapy and chemoradiation before surgery. OBJECTIVE: The aim of this study is to determine the favored treatment for locally advanced rectal cancer by comparing the cost-effectiveness of total neoadjuvant therapy and the current standard of care. DESIGN: Decision analytical modeling using long-term costs and 5-year disease-free survival was performed to determine the cost-effectiveness after total neoadjuvant therapy and the current standard of care. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters. SETTINGS: Centers for Medicare & Medicaid Services billing data perspective was adopted and outcomes modeled according to local and national databases and literature consensus. PATIENTS: Adult patients with stage II or III rectal cancer were selected. MAIN OUTCOME MEASURES: Cost-effectiveness in disease-free life-years, incremental cost-effectiveness ratio, and net monetary benefit were determined over a 5-year posttreatment period. The favored strategy was determined based on cost-effectiveness and sensitivity analyses. RESULTS: Cost-effectiveness for total neoadjuvant therapy was 40,708 $/life-year, and, for conventional therapy, cost-effectiveness was 44,248 $/life-year. Sensitivity analysis showed that, for an estimated total neoadjuvant therapy completion rate of 90%, total neoadjuvant therapy would remain the dominant strategy for any adjuvant chemotherapy completion rate of less than 93%. LIMITATIONS: The samples used to calculate completion rates are small, and survival probabilities are based on existing literature, local database values, and consensus estimates. The model encompasses a 5-year time period from diagnosis. CONCLUSIONS: Cost-effectiveness analysis shows that a strategy of total neoadjuvant therapy followed by radical surgery is favored over the current standard of care for locally advanced rectal cancer. Sensitivity analysis shows that a low rate of adjuvant chemotherapy administration plays a key role in decreasing the cost-effectiveness of the current standard of care. See Video Abstract at http://links.lww.com/DCR/A942.

Surgical and short‐term oncological safety of total neoadjuvant therapy in high‐risk locally advanced rectal cancer

“…13 Additionally, a cost-effectiveness analysis in terms of disease-free life-years, incremental cost-effectiveness ratio and net monetary benefit of TNT versus standard LCCRT by Wright et al concluded the former was more cost-effective and a sensitivity analysis showed that a low rate of adjuvant chemotherapy administration played a key role in decreasing the cost-effectiveness in the latter. 14 Like the RAPIDO cohort, we found no significant difference in acute toxicity between both groups, although there was an increased incidence of ≥grade 3 events in the TNT group as expected as a result of more intensive treatment. However, high doses per fraction in SCRT may result in late toxicity so long-term follow up of this study population will be necessary.…”

Cost-Effectiveness Analysis: Selective Use of Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer

“…Previous work has demonstrated that total neoadjuvant therapy is more cost-effective than nCRT and surgery followed by adjuvant chemotherapy; however, this current model included patients with both adjuvant and neoadjuvant chemotherapy, and comparing only total neoadjuvant therapy BU and SU patients could alter results. 26 Finally, in this study, patients who had a complete clinical response were not considered for a watch-and-wait approach; rather, all received surgery. Incorporating a watch-and-wait strategy would be a useful area of future research.…”

The multidisciplinary management of rectal cancer

“…This approach offers early systemic control, helps avoid postoperative chemotherapy-related toxicity and improves completion rates by delivering the therapy before surgery when the patients are most fit and compliant 41,42 . Studies show that TNT has similar oncological outcomes to postoperative chemotherapy, facilitates delivery of planned systemic therapy and nonoperative treatment strategies aimed at organ preservation, and is more cost-effective 36,42,43 .…”