Cost-effectiveness of Short-Course Radiation Therapy vs Long-Course Chemoradiation for Locally Advanced Rectal Cancer

Ann C Raldow,Aileen B Chen,Percy P Lee,Jennifer Y Wo,Marcia Russell,Theodore S Hong,James C Cusack,David P Ryan

doi:10.1001/jamanetworkopen.2019.2249

Abstract

Although both short-course radiotherapy and long-course chemoradiotherapy have been practiced in parallel for more than 15 years, no cost-effectiveness analysis comparing these 2 approaches in patients with locally advanced rectal cancer has been published. To analyze the cost-effectiveness of short-course radiotherapy vs long-course chemoradiotherapy for the treatment of patients with locally advanced rectal cancer. This economic evaluation used a cost-effectiveness model simulating 10-year outcomes for 1 million hypothetical patients aged 65 years with locally advanced rectal cancer treated with either short-course radiotherapy or long-course chemoradiotherapy, followed by surgery and chemotherapy. Utilities and probabilities from the literature and costs from the Healthcare Bluebook and Medicare fee schedules were used to determine incremental cost-effectiveness ratios. It was assumed that long-course chemoradiotherapy would result in higher rates of low anterior resection (LAR). To model preference-sensitive care, a 2-way sensitivity analysis was conducted in which the utilities of the no-evidence-of-disease (NED) states with LAR and abdominoperineal resection (APR) were simultaneously varied. The analysis was repeated for patients with distal rectal tumors. Analysis was conducted from January to October 2018. Short-course radiotherapy and long-course chemoradiotherapy. Incremental cost-effectiveness ratios. Short-course radiotherapy was the cost-effective strategy compared with long-course chemoradiotherapy (incremental cost-effectiveness ratio, $133 495 per quality-adjusted life-year). Two-way sensitivity analysis revealed that the cost-effective approach for a given patient depended on the utilities for the NED-LAR and NED-APR states. Assuming that a greater proportion of patients with locally advanced distal tumors undergoing long-course chemoradiotherapy (39%) would proceed to LAR compared with those treated with short-course radiotherapy (19%), long-course chemoradiotherapy was the cost-effective approach (incremental cost-effectiveness ratio, $61 123 per quality-adjusted life-year). Short-course radiotherapy was the cost-effective strategy compared with long-course chemoradiotherapy for patients with locally advanced rectal cancer. The cost-effectiveness of short-course radiotherapy vs long-course chemoradiotherapy was sensitive to the utilities of the NED-LAR and NED-APR health states, highlighting the importance of care that is sensitive to patient preference. Long-course chemoradiotherapy was the cost-effective approach for patients with distal tumors.

Highlights

Radiation therapy prior to total mesorectal excision has been shown to yield low rates of pelvic recurrence in the treatment of rectal cancer.[1,2,3,4,5] Two radiation treatment paradigms have emerged as effective: (1) long-course chemoradiotherapy (LCRT) (50.4 Gy in 28 fractions with concurrent fluorouracil-based chemotherapy) followed by delayed total mesorectal excision and (2) shortcourse radiotherapy (SCRT) (25 Gy in 5 fractions) followed by immediate surgical resection
Two-way sensitivity analysis revealed that the cost-effective approach for a given patient depended on the utilities for the NED-low anterior resection (LAR) and NED-abdominoperineal resection (APR) states
Short-course radiotherapy was the cost-effective strategy compared with long-course chemoradiotherapy for patients with locally advanced rectal cancer

Summary

Introduction

Radiation therapy prior to total mesorectal excision has been shown to yield low rates of pelvic recurrence in the treatment of rectal cancer.[1,2,3,4,5] Two radiation treatment paradigms have emerged as effective: (1) long-course chemoradiotherapy (LCRT) (50.4 Gy in 28 fractions with concurrent fluorouracil-based chemotherapy) followed by delayed total mesorectal excision and (2) shortcourse radiotherapy (SCRT) (25 Gy in 5 fractions) followed by immediate surgical resection. LCRT remains the standard of care in the United States, many countries treat locally advanced rectal adenocarcinoma with SCRT.[6] Supporters of SCRT point to patient convenience, lower cost, and less acute radiation toxicity. Those favoring LCRT have emphasized increased likelihood of tumor downstaging, allowing for increased rates of sphincter preservation for low-lying tumors and R0 resection in the setting of threatened mesorectal fascia. Given the generally favorable outcomes for locally advanced rectal cancer, proponents of LCRT have noted the potential increased risk of late radiation-induced toxic effects in the setting of hypofractionated radiation. While the Trans-Tasman Radiation Oncology Group (TROG)[3] and Bujko et al[5] reported no significant differences in late toxic effects between these 2 regimens to date, the median follow-up of this study is limited

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