Economic cost-utility analysis of stage-directed oesophageal cancer treatment

Herbert, Geraint L., Robinson, David B. T., Powell, Arfon G. ORCID: https://orcid.org/0000-0002-3740-8275, Abdelrahman, Tarig, Khalid, Usman and Lewis, Wyn G. 2024. Economic cost-utility analysis of stage-directed oesophageal cancer treatment. BJS Open 8 (2) , zrad159. 10.1093/bjsopen/zrad159

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Abstract

Introduction Oesophageal cancer (OC) treatment is guided by radiological diagnostic stage1, with prognosis worsening as stage advances2. Potentially curative treatment is possible in 30–40% of patients2,3. Treatments include definitive chemoradiotherapy or surgery, with or without neoadjuvant therapy4, and patients not considered suitable for curative treatment receive palliative treatments or Best Supportive Care (BSC)2,5. Clinical effectiveness of treatments can be estimated in terms of Quality-Adjusted Life Years (QALYs) to price a treatment’s cost-effectiveness6. The aim of this study was to estimate the cost-utility of curative treatment related to OC stage compared with BSC. The primary hypothesis was that OCs of earlier stage would prove cheaper to treat in fiscal terms than OCs of more advanced later stage. Methods Consecutive patients undergoing surgical treatment for OC diagnosed according to established protocols with curative intent within a regional cancer network from 2010 to 2020 were included in the analysis. The cost of 1-year’s treatment from referral was calculated based on current management standards. Primary outcome was overall survival (OS). Detailed methods can be found in Supplementary methods. Results 365 patients (median age 65 years (range 38–80), 308 male, 57 female, 263 neoadjuvant therapy) who underwent surgical treatment with curative intent for OC were included. Based on pathological and intraoperative assessment, 111 (30.4%) were stage I, 65 (17.8%) stage II, 118 (32.3%) stage III and 71 (19.5%) were analysed as stage IV. Of these, 331 had adenocarcinoma, 32 squamous cell carcinoma and two high-grade dysplasia. Median follow-up was 36 (interquartile range (i.q.r.) 34.9–39.0) months and median OS was 42.9 (95% c.i. 35.6 to 53.2) months with an average cost of the first year’s treatment of €30 916. This resulted in a QALY-adjusted survival of 34.3 months, with cost per QALY of €10 817. In patients who underwent curatively intended surgery, median survival in the patients receiving neoadjuvant chemotherapy followed by surgery (CS) was 35.8 (95% c.i. 26.5 to 45.1) months compared with 45.6 (95% c.i. 37.7 to 46.7) months in the patients receiving neoadjuvant chemoradiotherapy followed by surgery (CRS) and 50.8 (95% c.i. 39.4 to 47.2) months in patients receiving surgery (S) alone. The QALY-adjusted survival was 28.6 months in the CS cohort, compared with 36.5 in the CRS cohort and 40.6 in the S cohort. The cost per QALY for CS was €14 448, CRS €13 040 and S €5276. The CS cohort had a significantly lower proportion of patients with pTNM stage I and II disease (28.6%) compared with the CRS and S cohorts (66.7 and 69.6% respectively, P < 0.001). Data relating to QALY-adjusted survival and the cost per QALY, stratified by tumour stage, can be found in Table 1. The cost analysis of treating OC related to TNM stage and treatment modality can be found in Fig. 1. Median OS for patients receiving BSC reported in the literature is around 4 months7, with a Health State Utility Value (HSUV) of 0.56, equating to a QALY-adjusted survival of 2.24 months and a cost per QALY of €70 463.

Item Type:	Article
Date Type:	Publication
Status:	Published
Schools:	Medicine
Additional Information:	License information from Publisher: LICENSE 1: URL: https://creativecommons.org/licenses/by-nc/4.0/, Type: cc-by-nc
Publisher:	Oxford University Press
ISSN:	2474-9842
Date of First Compliant Deposit:	1 May 2024
Date of Acceptance:	1 December 2023
Last Modified:	01 May 2024 09:00
URI:	https://orca.cardiff.ac.uk/id/eprint/168552

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