Image-guided navigation for locally advanced primary and locally recurrent rectal cancer: Evaluation of its early cost-effectiveness.

Abstract

e16015 Background: Radical resection is an important prognostic factor in patients with locally advanced primary (LARC) and locally recurrent rectal cancer (LRRC), but achieving this can be challenging. Therefore, an intraoperative surgical navigation system has been developed, showing improved radical resection rates for LARC and LRRC. This study evaluates the early cost-effectiveness of navigated surgery in LARC and LRRC compared to standard surgery. Methods: Two Markov decision models; one for each indication, were used to estimate the expected costs and outcomes for navigated and standard surgery from a Dutch healthcare perspective over a 3-year time horizon. The models started with a decision tree resulting in a radical or non-radical resection. Subsequently, the Markov-models comprised the health states “stable disease”, “progression” and “death”. The input parameters were based on prospective (navigation cohort n = 33) and retrospective (control group n = 142) data collected at the Netherlands Cancer Institute, reference and unit prices and expert opinion. Quality-Adjusted Life Years (QALYs) were measured by the EQ5D-5L. Additionally, a probabilistic sensitivity analysis and a scenario analysis were performed. Results: Navigated surgery showed incremental costs of €3139 and €2857 in LARC and LRRC, respectively. For LARC, for navigation and standard surgery we found: 2.54 vs 2.52 Life Years (LYs), and 2.06 vs 2.04 QALYs. For LRRC we found 2.17 vs 2.11 LYs and 1.73 vs 1.67 QALYs. The base case analysis showed an Incremental Cost-Effectiveness Ratio (ICER) of €144,192 for LARC and €51,802 for LRRC per QALY gained. At a willingness to pay threshold of €80,000, navigated surgery is not cost- effective in LARC but is cost-effective in LRRC. When a hospital lacks a hybrid OR and needs to invest in one to use the navigation system, which will increase the ICERs for both indications. Finally, more utilization of the navigation system (12% to 50% utilization rate) shows ICERs of € 65,257 and €20,648 for LARC and LRRC, respectively. Conclusions: Based on the current data, the navigation system is expected to be cost-effective in LRRC and has the potential to become cost-effective in LARC. To decrease the costs, it is crucial to identify more surgical indications for image-guided navigation. Especially as in the near future, image-guided surgery is expected to be a standard option in surgical practice. As these findings are sensitive to uncertainty in the data, a randomized controlled trial is advised to perform for relevant indications.