Cost Analysis of Trans-oral Robotic Surgery Versus Radiation (+/-Chemotherapy) for Locally Advanced Tonsillar Cancer

Trans oral robotic surgery versus definitive chemoradiotherapy for oropharyngeal cancer: 10-year institutional experience.

Oncologic Outcomes in Patients with Oropharyngeal Squamous Cell Carcinoma Treated with TORS versus Definitive CRT

To compare quality of life (QOL) of patients who underwent transoral robotic surgery (TORS) alone, with adjuvant radiation therapy (RT), or adjuvant chemoradiation therapy (CRT) in the treatment of oropharyngeal squamous cell cancer (OPSCCA). Prospective cohort study. Medical records were reviewed for 111 patients treated for OPSCCA from 2008 to 2015. Patients were administered the Head and Neck Cancer Inventory (HNCI) to evaluate QOL preoperatively, and at 3 weeks, 3 months, 6 months, and 1 year postsurgery. QOL data were compared between 13 patients treated with TORS alone, 31 with adjuvant RT, and 67 with adjuvant CRT by a linear mixed effects model. Mean follow-up was 35 months. The HNCI response rates at 3 weeks and 3, 6, and 12 months were 80%, 60%, 55%, and 46%, respectively. TORS alone reported significantly higher eating scores than adjuvant RT or CRT at 3 and 6 months, and higher speech scores compared to adjuvant CRT at 3 months and adjuvant RT at 6 months. TORS alone and adjuvant RT reported less social disruption compared to adjuvant CRT at 3 months. Adjuvant CRT had consistently lower overall QOL scores until 6 months. No TORS-alone patient required percutaneous endoscopic gastrostomy, and no study patient required tracheostomy during treatment. TORS alone maintained higher QOL than adjuvant RT or CRT in eating, social function, speech, and overall QOL postsurgery. QOL and functional metrics were better for 6 months in TORS-alone patients, and at 12 months, the differences were not significant. 4. Laryngoscope, 128:403-411, 2018.

ABSTRACTObjectivesNutritional outcomes following transoral robotic surgery (TORS) for human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma (OPSCC) are poorly understood. This study evaluates how TORS, with or without adjuvant treatment, impacts swallowing and weight loss.MethodsAll patients treated with TORS for HPV‐associated OPSCC from January 2016 to December 2023 were included. Weight loss, functional oral intake, feeding tube dependence, patient demographics, and treatment course were collected from patients' electronic medical records.ResultsIn total, 160 patients with HPV‐associated OSPCC treated with TORS were included. 87.5% were male, with a median age of 60.0 years. Most patients were diagnosed with pT1 (53.8%) or pT2 (40.0%) and pN1 (78.1%) disease. 31.9% underwent TORS alone, while 42.5% received adjuvant radiation and 25.6% adjuvant chemoradiation. The median follow‐up time was 2.27 (range 0.26–7.56) years. 87.4% of patients underwent nasogastric tube placement during TORS. Prolonged postoperative nasogastric tube dependence was significantly associated with increased rates of feeding tube replacement (p < 0.001; 95% CI, 1.051–1.181) later during treatment. Weight loss from three months to three years postoperatively was significantly greater in patients who received adjuvant radiation and chemoradiation (p < 0.001), despite no significant difference in swallowing outcomes. There was no significant difference in weight loss between adjuvant radiation and chemoradiation groups.ConclusionsAdjuvant treatment following TORS is associated with significantly greater long‐term weight loss but does not significantly alter swallowing outcomes. Longer duration of nasogastric tube dependence in the postoperative period is associated with higher rates of enteral feeding dependence later in treatment.Level of Evidence3.

The present study is an economic evaluation comparing transoral robotic surgery (TORS) to (chemo)radiotherapy for the management of early T-classification oropharyngeal cancer. A societal perspective was adopted. Treatment for TORS and (chemo)radiotherapy were modeled using decision analysis and recurrences were modeled over a 10 year horizon with a Markov model. Model parameters were derived from systematic review. Deterministic and probabilistic sensitivity analyses were used to test model robustness. TORS demonstrated a cost savings of $1366 and an increase of 0.25 quality-adjusted life years (QALYs) per case in comparison to (chemo)radiotherapy. TORS was sensitive to variations in adjuvant therapy, costs, utilities, complications, and recurrence rates in deterministic and probabilistic sensitivity analysis. In two-way sensitivity analysis, with increasing adjuvant therapy for TORS and decreasing concurrent chemotherapy for radiotherapy, TORS is decreasingly cost-effective. TORS is cost-effective for treatment of early oropharyngeal cancer. Case selection to minimize adjuvant therapy ensures cost-effective treatment.

Oncologic outcomes and patient-reported quality of life in patients with oropharyngeal squamous cell carcinoma treated with definitive transoral robotic surgery versus definitive chemoradiation

Cost-Effectiveness Analysis of Chemoradiation Therapy Versus Transoral Robotic Surgery for Human Papillomavirus–Associated, Clinical N2 Oropharyngeal Cancer

Cost-Effectiveness Analysis of Radiation Therapy Versus Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma

To evaluate the cost-effectiveness of transoral robotic surgery (TORS) compared to intensity-modulated radiotherapy (IMRT) for early stage (T1-2, N0, M0) oropharyngeal squamous cell carcinoma (OPSCC). A Markov decision tree model with a 5-year time horizon was developed. Comparative groups were: i) TORS with concurrent ipsilateral neck dissection +/- adjunctive IMRT, and ii) primary IMRT. Primary outcome was cost/quality adjusted life year (QALY). Perspective was the United States third party payer. Costs and effects were discounted at a rate of 3.5%. A threshold and probabilistic sensitivity analysis were performed. TORS strategy cost $30,992 and provided 4.81 QALYs/patient. The IMRT strategy cost $26,033 and provided a total of 4.78 QALYs/patient. The incremental cost effectiveness ratio for TORS vs. IMRT in the reference case was $165,300/QALY. The probability that TORS is cost-effective compared to IMRT at a maximum willingness-to-pay threshold of $50,000/QALY is 42%. An IMRT strategy for management of early stage OPSCC is more likely to be cost-effective compared to TORS. To improve the value of TORS for early stage OPSCC, consolidating TORS procedures to create high-volume centers of excellence may be a potential strategy to increase incremental effectiveness and reduce incremental costs. J. Surg. Oncol. 2015 111:155-163. © 2015 Wiley Periodicals, Inc.

Utilization of Transoral Robotic Surgery in Patients With Oropharyngeal Squamous Cell Carcinoma and Its Impact on Survival and Use of Adjuvant Therapy Compared to Treatment With Definitive Radiation Therapy

Survival Impact of Transoral Robotic Surgery in Early-Stage Oropharyngeal Cancer

Treatment outcomes of transoral robotic and non-robotic surgeries to treat oropharyngeal, hypopharyngeal, and supraglottic squamous cell carcinoma: A multi-center retrospective observational study in Japan

Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR): an open-label, phase 2, randomised trial.

BackgroundIn 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.MethodsA 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.ResultsIn 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.ConclusionNon-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.

The treatment of oropharyngeal cancer has undergone a paradigm shift in the past 2 decades, with an increase in the use of nonoperative treatment owing to poor functional outcomes associated with traditional surgical approaches. Transoral robotic surgery (TORS) allows surgical resection of oropharyngeal cancer (OPC) with less morbidity through a minimally invasive approach. To investigate the relationship among TORS and short- and long-term outcomes and costs in surgically treated patients with OPC. Retrospective cross-sectional analysis of 3573 patients who underwent an ablative procedure for OPC in 2010 to 2012 using the MarketScan Commercial Claim and Encounters database. The association between TORS and short- and long-term outcomes, length of hospitalization, and treatment-related costs was analyzed using descriptive statistics and multivariate regression modeling. Transoral robotic surgery was performed in 304 surgical cases (8.5%); 94.7% of patients were 40 to 64 years old, and 70.7% were male. The use of TORS increased from 4.1% of surgical cases in 2010 to 13.2% of surgical cases in 2012. Patients who underwent TORS had a lower rate of tracheotomy during treatment (3.9% vs 11.4%), and posttreatment gastrostomy tube use (21.9% vs 34.2%), compared with patients undergoing non-TORS procedures. On multivariate analysis, TORS was not associated with significant differences in postoperative complications or length of hospitalization. There was no significant difference in the odds of receiving postoperative radiation therapy between patients who underwent TORS and those who did not; however, among patients receiving radiation therapy, chemoradiation was significantly less likely following TORS (odds ratio [OR], 0.52; 95% CI, 0.29-0.90). TORS was associated with significantly decreased odds of posttreatment gastrostomy (OR, 0.54; 95% CI. 0.30-0.95) and tracheostomy during treatment (OR, 0.17; 95% CI, 0.06-0.55) at 1 year, and was associated with significantly decreased overall treatment-related costs of care (mean incremental cost, -$22 724). The use of TORS for surgical resection of OPC is increasing in the United States and is associated with significantly lower use of adjuvant chemoradiation, late gastrostomy and tracheostomy dependence, and lower overall treatment-related costs of care. These data have implications for discussions of value in OPC care at a time of health care reform.