Abstract
PurposeTo evaluate the cost-effectiveness of preoperative short-course radiotherapy (SCRT, 5 × 5 Gy) plus FOLFOX4 versus long-course oxaliplatin and bolus of fluorouracil based preoperative long-course chemoradiotherapy (LCCRT, 50.4 Gy in 28 fractions) in the management of cT4 or advanced cT3 rectal cancer (RC), both of which have been reported to achieve similar clinical effect in the NCT00833131 trial.Materials and methodsA Markov decision-analytic model compared SCRT plus chemotherapy and LCCRT, by simulating three health states (disease-free survival (DFS), progressive disease (PD) and death). The primary outcomes were quality-adjusted life months (QALMs), costs, and incremental cost-effectiveness ratios (ICERs). Transition probabilities were based on the NCT00833131 trial. The costs were calculated from a Chinese payers’ perspective. Strategies were evaluated with a willingness-to-pay (WTP) threshold of $2370.47 (3 × GDP) per QALM gained. Sensitivity analysis was performed to model uncertainty in these parameters.ResultsThe overall costs for SCRT plus chemotherapy and LCCRT were $78,937 and $38,140 with effectiveness of 29.92 QALMs and 22.99 QALMs, respectively. SCRT plus chemotherapy increased costs and QALM by $40,797.34 and 6.93 compared to LCCRT, resulting in an ICER of $5884.56/QALM gained. In the DFS state, the whole cost for SCRT plus chemotherapy and LCCRT were $11,490.03 and $10,794.06 with an effectiveness of 21.70 QALMs and 19.65 QALMs, respectively. SCRT plus chemotherapy increased cost and QALM by $695.97 and 2.05 compared to LCCRT, resulting in a ICER of $339.50/QALM gained, which below the WTP. The utility associated with the DFS state was the most influential factor on the cost-effectiveness of SCRT plus chemotherapy. When the cost of PD state below $1920, the ICER of SCRT compared with LCCRT below the WTP.ConclusionCompared with LCCRT, SCRT plus chemotherapy is a more cost-effective strategy for locally advanced resectable RC in the DFS state as well as in the all states when the cost of PD state below $1920.
Highlights
Rectal cancer (RC) is one of the most frequent malignancies in the world and represents a major socioeconomic and health issue [1]
The utility associated with the diseasefree survival (DFS) state was the most influential factor on the cost-effectiveness of short-course radiotherapy (SCRT) plus chemotherapy
Preoperative short-course radiotherapy (SCRT) plus chemotherapy consisting of FOLFOX4 or preoperative long-course chemoradiotherapy (LCCRT) with oxaliplatin and boluses of 5- fluorouracil and leucovorin in combination with conventional surgery are recommended depending on the tumor location, infiltration depth of the tumor, and lymph node involvement, which improves local control and survival [5]
Summary
Rectal cancer (RC) is one of the most frequent malignancies in the world and represents a major socioeconomic and health issue [1]. Surgery is the basic treatment for RC, but for advanced RC, adjuvant radiotherapy with or without chemotherapy has been used widely to improve outcomes. It is well known for locally advanced disease, postoperative chemoradiotherapy (CRT) significantly improves both local control and overall survival as compared with surgery alone or surgery plus irradiation [3, 4]. Results showed shortterm preoperative radiotherapy decreased risk of local recurrence for irradiated patients at 2 years (2% vs 8%, p < 0.001) without a difference in overall survival (OS) for the patients with rectal cancer who undergo a standardized total mesorectal excision [6]. There is no international consensus on the use of these treatment schedules or the most appropriate patient selection for these schedules
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