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

Abstract

Purpose/Objective(s)Cost analysis is a useful tool in justifying the adoption of new treatment strategies with better clinical outcomes. In the past, a cost-effectiveness ratio (CER) of $5084 per quality-adjusted life year (QALY) gained has been used to justify the switch from 3D-CRT to IMRT for definitive treatment of oropharyngeal cancer. A CER of $27000 per QALY gained has been used to justify the switch from 3D-CRT to IMRT for definitive treatment of prostate cancer. Definitive chemoradiation has been a standard for locally advanced (Stage III or IV, non-metastatic) tonsillar cancer, sparing the morbidity associated with traditional forms of surgery. Trans-oral robotic surgery (TORS) is a minimally invasive approach which has been explored as an alternative to definitive chemoradiation; adjuvant radiation +/- chemotherapy still plays a role for postoperative patients.Materials/MethodsThree treatment approaches for locally advanced tonsillar cancer were analyzed 1: Definitive chemoradiation (CRT) to 70 Gy in 35 fractions with 3 cycles of concurrent cisplatin, 2: TORS plus adjuvant RT, 60 Gy in 30 fractions without chemotherapy, and 3: TORS plus adjuvant chemoradiation, 60 Gy in 30 fractions with 2 cycles of cisplatin. A proportion was used to determine how many QALYs must be added by TORS to justify its cost-effectiveness using the historical CERs discussed above.ResultsAt our institution, the cost of each treatment approach was as follows- Approach 1: $139504; Approach 2: $203755; Approach 3: $223755. TORS would need to add 12.6 QALYs when comparing approach 2 to 1 to be cost-effective per the oropharyngeal cancer CER. TORS would need to add 2.4 QALYs when comparing approach 2 to 1 to be cost-effective per the prostate cancer CER. TORS would need to add 16.6 QALYs when comparing approach 3 to 1 to be cost-effective per the oropharyngeal CER. TORS would need to add 3.1 QALYs when comparing approach 3 to 1 to be cost-effective per the prostate CER.ConclusionsWe performed a cost-analysis of the use of TORS for locally advanced tonsillar cancer. Historical data was used to help determine the clinical benefit that would be necessary with TORS to justify its additional cost. TORS would need to add at least 2.4 QALYs when compared with definitive CRT to justify transition over to TORS as a cost-effective advance in treatment. Further analysis of clinical outcomes data will enable a more complete cost-effectiveness analysis. However, given the limited survival of patients with locally advanced tonsillar cancer, the likelihood that TORS will provide a cost-effective clinical benefit may be low. Purpose/Objective(s)Cost analysis is a useful tool in justifying the adoption of new treatment strategies with better clinical outcomes. In the past, a cost-effectiveness ratio (CER) of $5084 per quality-adjusted life year (QALY) gained has been used to justify the switch from 3D-CRT to IMRT for definitive treatment of oropharyngeal cancer. A CER of $27000 per QALY gained has been used to justify the switch from 3D-CRT to IMRT for definitive treatment of prostate cancer. Definitive chemoradiation has been a standard for locally advanced (Stage III or IV, non-metastatic) tonsillar cancer, sparing the morbidity associated with traditional forms of surgery. Trans-oral robotic surgery (TORS) is a minimally invasive approach which has been explored as an alternative to definitive chemoradiation; adjuvant radiation +/- chemotherapy still plays a role for postoperative patients. Cost analysis is a useful tool in justifying the adoption of new treatment strategies with better clinical outcomes. In the past, a cost-effectiveness ratio (CER) of $5084 per quality-adjusted life year (QALY) gained has been used to justify the switch from 3D-CRT to IMRT for definitive treatment of oropharyngeal cancer. A CER of $27000 per QALY gained has been used to justify the switch from 3D-CRT to IMRT for definitive treatment of prostate cancer. Definitive chemoradiation has been a standard for locally advanced (Stage III or IV, non-metastatic) tonsillar cancer, sparing the morbidity associated with traditional forms of surgery. Trans-oral robotic surgery (TORS) is a minimally invasive approach which has been explored as an alternative to definitive chemoradiation; adjuvant radiation +/- chemotherapy still plays a role for postoperative patients. Materials/MethodsThree treatment approaches for locally advanced tonsillar cancer were analyzed 1: Definitive chemoradiation (CRT) to 70 Gy in 35 fractions with 3 cycles of concurrent cisplatin, 2: TORS plus adjuvant RT, 60 Gy in 30 fractions without chemotherapy, and 3: TORS plus adjuvant chemoradiation, 60 Gy in 30 fractions with 2 cycles of cisplatin. A proportion was used to determine how many QALYs must be added by TORS to justify its cost-effectiveness using the historical CERs discussed above. Three treatment approaches for locally advanced tonsillar cancer were analyzed 1: Definitive chemoradiation (CRT) to 70 Gy in 35 fractions with 3 cycles of concurrent cisplatin, 2: TORS plus adjuvant RT, 60 Gy in 30 fractions without chemotherapy, and 3: TORS plus adjuvant chemoradiation, 60 Gy in 30 fractions with 2 cycles of cisplatin. A proportion was used to determine how many QALYs must be added by TORS to justify its cost-effectiveness using the historical CERs discussed above. ResultsAt our institution, the cost of each treatment approach was as follows- Approach 1: $139504; Approach 2: $203755; Approach 3: $223755. TORS would need to add 12.6 QALYs when comparing approach 2 to 1 to be cost-effective per the oropharyngeal cancer CER. TORS would need to add 2.4 QALYs when comparing approach 2 to 1 to be cost-effective per the prostate cancer CER. TORS would need to add 16.6 QALYs when comparing approach 3 to 1 to be cost-effective per the oropharyngeal CER. TORS would need to add 3.1 QALYs when comparing approach 3 to 1 to be cost-effective per the prostate CER. At our institution, the cost of each treatment approach was as follows- Approach 1: $139504; Approach 2: $203755; Approach 3: $223755. TORS would need to add 12.6 QALYs when comparing approach 2 to 1 to be cost-effective per the oropharyngeal cancer CER. TORS would need to add 2.4 QALYs when comparing approach 2 to 1 to be cost-effective per the prostate cancer CER. TORS would need to add 16.6 QALYs when comparing approach 3 to 1 to be cost-effective per the oropharyngeal CER. TORS would need to add 3.1 QALYs when comparing approach 3 to 1 to be cost-effective per the prostate CER. ConclusionsWe performed a cost-analysis of the use of TORS for locally advanced tonsillar cancer. Historical data was used to help determine the clinical benefit that would be necessary with TORS to justify its additional cost. TORS would need to add at least 2.4 QALYs when compared with definitive CRT to justify transition over to TORS as a cost-effective advance in treatment. Further analysis of clinical outcomes data will enable a more complete cost-effectiveness analysis. However, given the limited survival of patients with locally advanced tonsillar cancer, the likelihood that TORS will provide a cost-effective clinical benefit may be low. We performed a cost-analysis of the use of TORS for locally advanced tonsillar cancer. Historical data was used to help determine the clinical benefit that would be necessary with TORS to justify its additional cost. TORS would need to add at least 2.4 QALYs when compared with definitive CRT to justify transition over to TORS as a cost-effective advance in treatment. Further analysis of clinical outcomes data will enable a more complete cost-effectiveness analysis. However, given the limited survival of patients with locally advanced tonsillar cancer, the likelihood that TORS will provide a cost-effective clinical benefit may be low.