Abstract
ObjectiveTo assess the cost-effectiveness of sentinel lymph node mapping compared to risk factor assessment and routine full lymph node dissection for the assessment of lymph nodes in patients with low- and intermediate-risk endometrioid endometrial cancer. MethodsA decision-analytic model was designed to compare three lymph node assessment strategies in terms of costs and effects: 1) sentinel lymph node mapping; 2) post-operative risk factor assessment (adjuvant therapy based on clinical and histological risk factors); 3) full lymph node dissection. Input data were derived from systematic literature searches and expert opinion. QALYs were used as measure of effectiveness. The model was built from a healthcare perspective and the impact of uncertainty was assessed with sensitivity analyses. ResultsBase-case analysis showed that sentinel lymph node mapping was the most effective strategy for lymph node assessment in patients with low- and intermediate-risk endometrial cancer. Compared to risk factor assessment it was more costly, but the incremental cost effectiveness ratio stayed below a willingness-to-pay threshold of €20,000 with a maximum of €9637/QALY. Sentinel lymph node mapping was dominant compared to lymph node dissection since it was more effective and less costly. Sensitivity analyses showed that the outcome of the model was robust to changes in input values. With a willingness-to-pay threshold of €20,000 sentinel lymph node mapping remained cost-effective in at least 74.3% of the iterations. ConclusionSentinel lymph node mapping is the most cost-effective strategy to guide the need for adjuvant therapy in patients with low and intermediate risk endometrioid endometrial cancer.
Highlights
Health care costs have risen drastically over the last decade and are expected to continue to rise
Two randomized controlled trials showed no benefits from lymph node dissection in low- and intermediate-risk endometrial cancer, while it may lead to increased morbidity such as lymphedema and lymphocysts. [11,12,13] The third approach, sentinel lymph node (SLN) mapping, involves a less invasive procedure, with selective and limited removal of lymph nodes and improved histological procedures by ultrastaging of the specific nodes
A decision-analytic model was designed to evaluate the costeffectiveness of the three lymph node assessment strategies to guide the need for adjuvant therapy: 1) adjuvant therapy based on SLN mapping (SLN); 2) adjuvant therapy based on post-operative risk factor assessment; 3) adjuvant therapy based on full lymph node dissection (LND)
Summary
Health care costs have risen drastically over the last decade and are expected to continue to rise. Since endometrial cancer is a common malignancy with an increasing incidence entailing high health care costs, a cost-effective treatment of endometrial cancer patients is of great importance [1,2]. The first approach is adjuvant treatment based on risk classification (‘risk factor assessment’; tumor grade, myometrial invasion, lymph-vascular space invasion (LVSI) and age), without removal of any lymph nodes during the surgical procedure. This strategy could lead to either over- or undertreatment due to incorrectly classified patients. [40,41] Patients without any side effects or recurrent disease are assumed to be in perfect health and are assigned a utility value of 1. The annual discount rate for effects was 1.5%. [38]
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