Cost-Effectiveness Analysis of PET-CT Surveillance After Treatment of Human Papillomavirus-Positive Oropharyngeal Cancer

OBJECTIVE

To determine the cost-effectiveness of surveillance imaging with PET/CT scan among patients with human papillomavirus-positive oropharyngeal squamous cell carcinoma.

STUDY DESIGN

Cost-effectiveness analysis.

SETTING

Oncologic care centers in the United States with head and neck oncologic surgeons and physicians.

METHODS

We compared the cost-effectiveness of 2 posttreatment surveillance strategies: clinical surveillance with the addition of PET/CT scan versus clinical surveillance alone in human papillomavirus-positive oropharyngeal squamous cell carcinoma patients. We constructed a Markov decision model which was analyzed from a third-party payer's perspective using 1-year Markov cycles and a 30-year time horizon. Values for transition probabilities, costs, health care utilities, and their studied ranges were derived from the literature.

RESULTS

The incremental cost-effectiveness ratio for PET/CT with clinical surveillance versus clinical surveillance alone was $89,850 per quality-adjusted life year gained. Flexible fiberoptic scope exams during clinical surveillance would have to be over 51% sensitive or PET/CT scan cost would have to exceed $1678 for clinical surveillance alone to be more cost-effective. The willingness-to-pay threshold at which imaging surveillance was equally cost-effective to clinical surveillance was approximately $80,000/QALY.

CONCLUSION

Despite lower recurrence rates of human papillomavirus-positive oropharyngeal cancer, a single PET/CT scan within 6 months after primary treatment remains a cost-effective tool for routine surveillance when its cost does not exceed $1678. The cost-effectiveness of this strategy is also dependent on the clinical surveillance sensitivity (flexible fiberoptic pharyngoscopy), and willingness-to-pay thresholds which vary by country.

Evaluation of Preference and Utility Measures for Transoral Thyroidectomy

BACKGROUND

Traditional, trans-cervical thyroidectomy results in the presence of a neck scar, which has been shown to correlate with lower quality of life and lower patient satisfaction. Transoral thyroid surgery (TOTS) has been utilized as an alternative approach to avoid a cutaneous incision and scar by accessing the neck and thyroid through the oral cavity. This study was designed to evaluate patient preference through health-state utility scores for TOTS as compared to conventional trans-cervical thyroidectomy.

METHODS

In this cross-sectional study, patient preferences were elicited for TOTS and trans-cervical thyroidectomy with the use of an online survey. Respondents were asked to consider 4 hypothetical health scenarios involving thyroid surgery with varying approaches. Health-state utility scores were elicited using visual analog scale and standard gamble exercises.

RESULTS

Overall, 516 respondents completed the survey, of whom 261 (50.6%) were included for analysis, with a mean age of 41.5 years (SD 14.9 years), including 171 (65.5%) females. Health utility scores were similar for TOTS and conventional transcervical techniques. Statistically significant differences in the standard gamble utility score were noted for gender and ethnicity across all scenarios. Comparisons of visual analog score utilities were not statistically significant based on respondent demographics.

CONCLUSION

Preferences for TOTS and trans-cervical thyroidectomy did not significantly differ in the current study. Females and white ethnicity indicated stronger preference for a TOTs approach compared to males and other ethnicities, respectively. Some literature suggests certain types of patients who might prefer minimally invasive thyroidectomy more so than other patients-in keeping with the current findings of this study.

Patient reported outcomes based on EQ-5D-5L questionnaires in head and neck cancer patients: a real-world study

OBJECTIVE

Health economic comparisons of various therapies are often based on health-related quality of life (HRQOL) using EQ-5D questionnaires within the framework of clinical trials. This real-world study prospectively evaluates the patient reported outcomes (PROs)-based HRQOL of head-and-neck (H&N) cancer patients undergoing modern radiotherapy (RT) to reflect PRO trajectories.

METHODS

All H&N cancer patients treated in our clinic between July 2019 and December 2020 who completed the self-reported validated EQ-5D-5L questionnaire (health state index (HI) and Visual Analog Scale (VAS)) at baseline, end of radiotherapy, and at each respective follow up (FU) were included. Descriptive analysis of clinical and sociodemographic data, the frequency and level of each dimension was conducted. To assess the significance of therapy-induced HRQOL changes within and between the group, a distribution-based approach was used.

RESULTS

Altogether, 366 participants completed a total of 565 questionnaires. For the whole cohort, HI at baseline was 0.804 (±0.208), 0.830 (±0.162) at RT completion, 0.812 (±0.205) at the first follow-up, and 0.769 (±0.224) at the second follow-up. The respective VAS values were 62.06 (±23,94), 66.73 (±82.20), 63.30 (±22.74), and 65.48 (±23.39). Females showed significantly lower HI values compared to males, but only at baseline (p = 0.034). Significantly lower HI values were also seen in patients with definitive RT as compared to adjuvant RT at baseline (p = 0.023), the second follow-up (p = 0.047), and the third follow-up (p = 0.010). As compared to outpatients, inpatients had significantly lower HI values at RT completion (p = 0.017), the second follow-up (p = 0.007), and the third follow-up (p = 0.031). Subgroup analyses by age (< 65 vs. ≥65) and smoking status (smokers vs. non-smokers) showed no difference at any time point.

CONCLUSION

PROs demonstrated detectability of time- and intra-/inter-group therapy-induced HRQOL changes. A further detailed exploration of EQ-5D-5L responsiveness for H&N cancer patients is required.

Increasing HPV vaccination coverage to prevent oropharyngeal cancer: A cost-effectiveness analysis

The incidence of oropharyngeal cancer (OPC) has been rising, especially among middle-aged men. While Human Papillomavirus (HPV) has been irrevocably implicated in the pathogenesis of oropharyngeal cancer (OPC), the current HPV vaccination uptake rate remains low in the US. The aim of our study was to evaluate the impact of increased HPV vaccination coverage on HPV-associated OPC incidence and costs. A decision analytic model was constructed for hypothetical cohorts of 9-year-old boys and girls. Two strategies were compared: 1) Maintaining the current vaccination uptake rates; 2) Increasing HPV vaccination uptake rates to the Healthy People 2030 target (80%) for both sexes. Increasing HPV vaccination coverage rates to 80% would be expected to prevent 5,339 OPC cases at a cost of $0.57 billion USD. Increased HPV vaccination coverage would result in 7,430 quality-adjusted life year (QALY) gains in the overall population, and it is estimated to be cost-effective for males with an incremental cost-effectiveness ratio of $86,940 per QALY gained under certain conditions. Expanding HPV vaccination rates would likely provide a cost-effective way to reduce the OPC incidence, particularly among males.

Quality of life and health-related utility after trans-oral surgery for head and neck cancers

Purpose

The purpose of this study was to assess utility coefficients of health states following two minimally invasive surgical approaches for head and neck cancer, namely trans-oral robotic surgery and trans-oral laser microsurgery. Those utility coefficients will be later exploited in an economic evaluation study comparing the two approaches.

Methods

The above cited economic evaluation will be done from the Swiss healthcare system perspective and, as such, Swiss healthcare professionals were interviewed to elicit utility coefficients. Health states, ranging from remission to palliative care, were described using clinical vignettes. A computerized tool (UceWeb) implementing standard gamble and rating scale methods was used.

Results

Utility coefficients for 18 different health states were elicited with the two methods from 47 individuals, for a total of 1692 values. Elicited values varied from 0.980 to 0.213. Comparison with values elicited in previous studies show the need for population-specific elicitation, mainly for the worst health states.

Conclusion

Herein we report health utility coefficients for the Swiss population for health states following minimally invasive trans-oral surgery. This study provides utility values that can be used not only for a specific cost-utility analysis, but also for future studies involving the same health states.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01836-3.

Liquid biopsy posttreatment surveillance in endemic nasopharyngeal carcinoma: a cost-effective strategy to integrate circulating cell-free Epstein-Barr virus DNA

BACKGROUND

The optimal posttreatment surveillance strategy for nasopharyngeal carcinoma (NPC) remains unclear. Circulating cell-free Epstein-Barr virus (cfEBV) DNA has been recognized as a promising biomarker to facilitate early detection of NPC recurrence. Therefore, we aim to determine whether integrating circulating cfEBV DNA into NPC follow-up is cost-effective.

METHODS

For each stage of asymptomatic nonmetastatic NPC patients after complete remission to primary NPC treatment, we developed a Markov model to compare the cost-effectiveness of the following surveillance strategies: routine follow-up strategy, i.e., (1) routine clinical physical examination; routine imaging strategies, including (2) routine magnetic resonance imaging plus computed tomography plus bone scintigraphy (MRI + CT + BS); and (3) routine ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT); cfEBV DNA-guided imaging strategies, including (4) cfEBV DNA-guided MRI + CT + BS and (5) cfEBV DNA-guided PET/CT. Clinical probabilities, utilities, and costs were derived from published studies or databases. Sensitivity analyses were performed.

RESULTS

For all disease stages, cfEBV DNA-guided imaging strategies demonstrated similar survival benefits but were considerably more economical than routine imaging strategies. They only required approximately one quarter of the number of imaging studies compared with routine imaging strategies to detect one recurrence. Specifically, cfEBV DNA-guided MRI + CT + BS was most cost-effective for stage II (incremental cost-effectiveness ratio [ICER] $57,308/quality-adjusted life-year [QALY]) and stage III ($46,860/QALY) patients, while cfEBV DNA-guided PET/CT was most cost-effective for stage IV patients ($62,269/QALY). However, routine follow-up was adequate for stage I patients due to their low recurrence risk.

CONCLUSIONS

The cfEBV DNA-guided imaging strategies are effective and cost-effective follow-up methods in NPC. These liquid biopsy-based strategies offer evidence-based, stage-specific surveillance modalities for clinicians and reduce disease burden for patients.

Optimizing oropharyngeal cancer management by using proton beam therapy: trends of cost-effectiveness

Background

Proton beam therapy (PBT) is a new-emerging cancer treatment in China but its treatment costs are high and not yet covered by Chinese public medical insurance. The advanced form of PBT, intensity-modulated proton radiation therapy (IMPT), has been confirmed to reduce normal tissue complication probability (NTCP) as compared to conventional intensity-modulated photon-radiation therapy (IMRT) in patients with oropharyngeal cancer (OPC). Herein, we evaluated the cost-effectiveness and applicability of IMPT versus IMRT for OPC patients in China, aiming at guiding the proper use of PBT.

Methods

A 7-state Markov model was designed for analysis. Base-case evaluation was performed on a 56-year-old (median age of OPC in China) patient under the assumption that IMPT could provide a 25% NTCP-reduction in long-term symptomatic dysphagia and xerostomia. Model robustness was examined using probabilistic sensitivity analysis, cohort analysis, and tornado diagram. One-way sensitivity analyses were conducted to identify the cost-effective scenarios. IMPT was considered as cost-effective if the incremental cost-effectiveness ratio (ICER) was below the societal willingness-to-pay (WTP) threshold.

Results

Compared with IMRT, IMPT provided an extra 0.205 quality-adjusted life-year (QALY) at an additional cost of 34,926.6 US dollars ($), and had an ICER of $170,082.4/ QALY for the base case. At the current WTP of China ($33,558 / QALY) and a current IMPT treatment costs of $50,000, IMPT should provide a minimum NTCP-reduction of 47.5, 50.8, 55.6, 63.3 and 77.2% to be considered cost-effective for patient age levels of 10, 20, 30, 40 and 50-year-old, respectively. For patients at the median age level, reducing the current IMPT costs ($50,000) to a $30,000 level would make the minimum NTCP-reduction threshold for “cost-effective” decrease from 91.4 to 44.6%, at the current WTP of China (from 69.0 to 33.5%, at a WTP of $50,000 / QALY; and from 39.7 to 19.1%, at a WTP of $100,000 / QALY).

Conclusions

Cost-effective scenarios of PBT exist in Chinese OPC patients at the current WTP of China. Considering a potential upcoming increase in PBT use in China, such cost-effective scenarios may further expand if a decrease of proton treatment costs occurs or an increase of WTP level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08638-2.

Economic evaluations comparing Tran-oral robotic surgery and radiotherapy in oropharyngeal squamous cell carcinoma: A systematic review

BACKGROUND

Trans-oral robotic surgery (TORS) and primary radiotherapy are the two modalities used to treat early T stage oropharyngeal squamous cell carcinoma(OPSCC). Prior literature including a recent randomized controlled trial have not shown the superiority of one modality over the other. When the modalities have similar outcomes, cost-effectiveness have an important role in deciding on the appropriate treatment. There are economic evaluations comparing the two modality with contradicting conclusions. The purpose of this review is to synthesise the evidence.

METHODS

This is a systematic review of economic evaluations on the treatment modalities for OPSCC, namely TORS versus radiotherapy. The main outcome measures were the Cost-utility results reported as the effectiveness and costs separately and as part of the Incremental Cost-Effectiveness Ratio.

RESULTS

Literature search identified five articles reporting cost-utility analysis, eligible for the review. A strategy is considered to be dominant when the effectiveness achieved was more at a lower cost, compared to the comparator. At the willingness to pay (WTP) threshold of 50,000 to 100,000 USD per Quality Adjusted Life-Year (QALY), three studies showed dominance of strategies in the base case analysis (TORS in two and Primary Chemoradiotherapy in one). Two of the articles studied node negative patients, one of them favored TORS. Three articles had node positive patients and two of them favored TORS and one favored chemoradiotherapy in the base case analysis. On sensitivity analysis, adjuvant treatment was found to be the detrimental factor affecting the cost-effectiveness.

CONCLUSIONS

TORS can be considered a cost-effective strategy in early T stage OPSCC, if the addition of adjuvant therapy involving radiotherapy can be avoided. Literature have shown that around 70% of the early cancers would require adjuvant treatment. This implies the importance of case selection while considering TORS as the initial treatment modality.

Utility Outcome Measures for the Treatment of Ameloblastomas during Childhood

Our objective was to determine the potential impact of the surgical treatment of ameloblastoma in children through validated health state utility outcome measures.

Cost Considerations for Robotic Surgery

Transoral robotic surgery (TORS) is a rapidly growing diagnostic and therapeutic modality in otolaryngology-head and neck surgery, having already made a large impact in the short time since its inception. Cost-effectiveness analysis is complex, and a thorough cost-effectiveness inquiry should analyze not only financial consequences but also impact on the health state of the patient. The cost-effectiveness of TORS is still under scrutiny, but the early data suggest that TORS is a cost-effective method compared with other available options when used in appropriately selected patients.

Quality of Life Implications After Transoral Robotic Surgery for Oropharyngeal Cancers

Oropharyngeal cancers and their treatment can exquisitely affect a patient's quality of life and functional outcome. Transoral robotic surgery offers a minimally invasive surgical approach that mitigates injury from traditional open surgical approaches and offers a treatment more likely to have short-term side effects compared with nonsurgical treatment. Feeding tube dependence, oral intake, and swallowing questionnaires, in addition to swallowing evaluations provide a snapshot of a patient's current swallowing function. Investigation of patient-reported quality-of-life outcomes allows for understanding of their symptomatology and the comparison of different treatment strategies.

Transoral robotic surgery vs open surgery in head and neck cancer. A systematic review of the literature

Background

TORS has become one of the latest surgical alternatives in the treatment of oropharynx squamous cell carcinomas (OPSCC) and has become increasingly accepted by surgeons as a treatment option. Surgical robots were designed for various purposes, such as allowing remote telesurgery, and eliminating human factors like trembling. The study aimed to compare systematic review of the available literature in order to evaluate the safety and efficacy of Transoral Robotic Surgery (TORS) compared with open surgery.

Material and Methods

We performed a systematic review of the available literature in order to evaluate the safety and effectiveness of TORS compared with open surgery. We compared TORS and open surgery based on 16 outcomes divided in to 3 groups: intra-operative complications, post-operative complications, and functional and oncologic outcomes. An electronic search of observational studies was carried out using the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Oral Health Group Trials Register, and Scielo. Data analysis was carried out in accordance to Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) and the quality of the studies were evaluated using the Newcastle-Ottawa Scale. No language restrictions were imposed.

Results

From the 4 studies identified (Newcastle-Ottawa Scale mean score 6.5), 371 patients were revised (186 patients were treated with TORS and 185 with conventional surgery). Overall, TORS, when compared with open surgery, appears to have better functional results (less hospital time, decannulation) and fewer intraoperative and post-operative complications. There is no significant difference when assessing the oncological outcomes (positive margins, survival rate) when comparing both techniques.

Conclusions

TORS has an overall better functional outcome, and less intraoperative and postoperative complications with no difference in positive margins and survival rate when compared with conventional therapy.

Key words:Transoral Robotic Surgery, TORS, open surgery, conventional surgery, head and neck cancer, oral cancer.

Comparative cost of transoral robotic surgery and radiotherapy (IMRT) in early stage tonsil cancer

PURPOSE

To compare treatment costs and cost-effectiveness for transoral robotic surgery (TORS) and definitive intensity-modulated radiotherapy (IMRT) in managing early stage tonsil cancer.

MATERIALS AND METHODS

Direct treatment costs for surgery and IMRT were calculated from SEER-Medicare data for a cohort with clinically early stage (cT1/2N0) p16+ tonsillar squamous cell carcinoma from Kaiser Permanente Southern California Health Plan between 2012 and 2017. A Markov decision tree model with a 5-year time horizon was then applied to the cohort which incorporated costs associated with treatment, surveillance, and recurrence.

RESULTS

IMRT cost up to $19,000 more (35%) than TORS in direct treatment costs. When input into the Markov model, TORS dominated IMRT with lower cost and better effectiveness over a range of values.

CONCLUSION

TORS is a more cost-effective treatment method than IMRT in early stage (cT1/2N0) tonsil cancer.

Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR): an open-label, phase 2, randomised trial

BACKGROUND

Transoral robotic surgery (TORS) with concurrent neck dissection has supplanted radiotherapy in the USA as the most common treatment for oropharyngeal squamous cell carcinoma (OPSCC), yet no randomised trials have compared these modalities. We aimed to evaluate differences in quality of life (QOL) 1 year after treatment.

METHODS

The ORATOR trial was an investigator-initiated, multicentre, international, open-label, parallel-group, phase 2, randomised study. Patients were enrolled at six hospitals in Canada and Australia. We randomly assigned (1:1) patients aged 18 years or older, with Eastern Cooperative Oncology Group scores of 0-2, and with T1-T2, N0-2 (≤4 cm) OPSCC tumour types to radiotherapy (70 Gy, with chemotherapy if N1-2) or TORS plus neck dissection (with or without adjuvant chemoradiotherapy, based on pathology). Following stratification by p16 status, patients were randomly assigned using a computer-generated randomisation list with permuted blocks of four. The primary endpoint was swallowing-related QOL at 1 year as established using the MD Anderson Dysphagia Inventory (MDADI) score, powered to detect a 10-point improvement (a clinically meaningful change) in the TORS plus neck dissection group. All analyses were done by intention to treat. This study is registered with ClinicalTrials.gov (NCT01590355) and is active, but not currently recruiting.

FINDINGS

68 patients were randomly assigned (34 per group) between Aug 10, 2012, and June 9, 2017. Median follow-up was 25 months (IQR 20-33) for the radiotherapy group and 29 months (23-43) for the TORS plus neck dissection group. MDADI total scores at 1 year were mean 86·9 (SD 11·4) in the radiotherapy group versus 80·1 (13·0) in the TORS plus neck dissection group (p=0·042). There were more cases of neutropenia (six [18%] of 34 patients vs none of 34), hearing loss (13 [38%] vs five [15%]), and tinnitus (12 [35%] vs two [6%]) reported in the radiotherapy group than in the TORS plus neck dissection group, and more cases of trismus in the TORS plus neck dissection group (nine [26%] vs one [3%]). The most common adverse events in the radiotherapy group were dysphagia (n=6), hearing loss (n=6), and mucositis (n=4), all grade 3, and in the TORS plus neck dissection group, dysphagia (n=9, all grade 3) and there was one death caused by bleeding after TORS.

INTERPRETATION

Patients treated with radiotherapy showed superior swallowing-related QOL scores 1 year after treatment, although the difference did not represent a clinically meaningful change. Toxicity patterns differed between the groups. Patients with OPSCC should be informed about both treatment options.

FUNDING

Canadian Cancer Society Research Institute Grant (#701842), Ontario Institute for Cancer Research Clinician-Scientist research grant, and the Wolfe Surgical Research Professorship in the Biology of Head and Neck Cancers grant.

Treatment preferences in human papillomavirus-associated oropharyngeal cancer

The population of survivors with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV-OPSCC) is rising. The improved prognosis of this etiologic subset is reflected in new staging guidelines as well as ongoing deintensification trials aiming to preserve excellent survival while decreasing treatment-related toxicities. However, as staging criteria and treatment standards evolve in the era of transoral surgery and deintensification, little is known regarding the needs and treatment preferences of patients with HPV-OPSCC. Herein, the current knowledge regarding treatment preferences and priorities, quality of life and concerns among patients with HPV-OPSCC is reviewed.

Cost-Effectiveness Analysis of Intensity Modulated Radiation Therapy Versus Proton Therapy for Oropharyngeal Squamous Cell Carcinoma

PURPOSE

To compared the cost-effectiveness of intensity modulated proton beam therapy (PBT) and intensity modulated radiation therapy (IMRT) in the management of stage III-IVB oropharynx cancer (OPC).

METHODS AND MATERIALS

A Markov model was constructed to compare IMRT with PBT for a 65-year-old patient with stage IVA OPSCC. We assumed PBT led to a 25% reduction in long-term xerostomia, short-term dysgeusia, and the need for gastrostomy tube. Fewer dental complications were also expected with PBT. Incremental cost-effectiveness ratios (ICERs) were calculated, and value of information analyses were performed. The societal willingness-to-pay was defined as $100K per quality-adjusted life year (QALY).

RESULTS

The ICERs for PBT for favorable human papillomavirus (HPV)-positive OPC were $288,000/QALY and $390,000/QALY in the payer perspective (PP) and societal perspective, respectively. Under nearly every scenario, PBT was not cost-effective, with ICERs above $150,000/QALY in the PP. The ICERs for HPV-negative OPC were typically greater than $250K/QALY in both perspectives. For HPV-positive patients, the ICER was less than $100,000/QALY in the PP only in younger patients who experienced a 50% reduction in both xerostomia and gastrostomy use. On probabilistic sensitivity analyses, there were 0% and 0.4% probabilities that PBT was cost-effective for 65- and 55-year old patients, respectively. The value of information was zero or negligible for all ages and perspectives at willingness-to-pay of $100,000/QALY and only meaningful in the PP for younger patients at a willingness-to-pay of $150,000/QALY.

CONCLUSIONS

Intensity modulated proton beam therapy was only cost-effective in the PP if assumed to achieve profound reductions in long-term morbidity for younger patients; it was never cost-effective in the societal perspective. Prospective data are needed (and may be valuable) to better characterize the comparative toxicities of these treatments but are unlikely to change this calculation, except potentially in the most favorable cohort of patients.

Cost-effectiveness of nivolumab for recurrent or metastatic head and neck cancer☆

OBJECTIVE

Nivolumab is the first drug to demonstrate a survival benefit for platinum-refractory recurrent or metastatic head and neck cancer. We performed a cost-utility analysis to assess the economic value of nivolumab as compared to alternative standard agents in this context.

MATERIALS AND METHODS

Using data from the CheckMate 141 trial, we constructed a Markov simulation model from the US payer's perspective to evaluate the cost-effectiveness of nivolumab compared to physician choice of either cetuximab, methotrexate or docetaxel. Alternative strategies considered included: single-agent cetuximab, methotrexate or docetaxel, or first testing for PD-L1 to select for nivolumab. Costs were extracted from Medicare and utilities from the literature and CheckMate. Probabilistic sensitivity analysis (PSA) was used to evaluate parameter uncertainty. $100,000/QALY was the primary threshold for cost-effectiveness.

RESULTS

When comparing nivolumab to the standard arm of CheckMate, nivolumab demonstrated an incremental cost-effectiveness ratio (ICER) of $140,672/QALY. When comparing standard therapies, methotrexate was the most cost-effective with similar results for docetaxel. Nivolumab was cost-effective compared to single-agent cetuximab (ICER $89,786/QALY). Treatment selection by PD-L1 immunohistochemistry did not markedly improve the cost-effectiveness of nivolumab. Factors likely to positively impact the cost-effectiveness of nivolumab include better baseline quality-of-life, poor tolerability of standard treatments and/or a lower cost of nivolumab.

CONCLUSIONS

Nivolumab is preferred to single-agent cetuximab but requires a willingness-to-pay of at least $150,000/QALY to be considered cost-effective when compared to docetaxel or methotrexate. Selection by PD-L1 does not markedly improve the cost-effectiveness of nivolumab. This informs patient selection and clinical care-path development.

Cost-effectiveness analysis of PET-CT-guided management for locally advanced head and neck cancer

BACKGROUND

A recent large United Kingdom (UK) clinical trial demonstrated that positron-emission tomography-computed tomography (PET-CT)-guided administration of neck dissection (ND) in patients with advanced head and neck cancer after primary chemo-radiotherapy treatment produces similar survival outcomes to planned ND (standard care) and is cost-effective over a short-term horizon. Further assessment of long-term outcomes is required to inform a robust adoption decision. Here we present results of a lifetime cost-effectiveness analysis of PET-CT-guided management from a UK secondary care perspective.

METHODS

Initial 6-month cost and health outcomes were derived from trial data; subsequent incidence of recurrence and mortality was simulated using a de novo Markov model. Health benefit was measured in quality-adjusted life years (QALYs) and costs reported in 2015 British pounds. Model parameters were derived from trial data and published literature. Sensitivity analyses were conducted to assess the impact of uncertainty and broader National Health Service (NHS) and personal social services (PSS) costs on the results.

RESULTS

PET-CT management produced an average per-person lifetime cost saving of £1485 and an additional 0.13 QALYs. At a £20,000 willingness-to-pay per additional QALY threshold, there was a 75% probability that PET-CT was cost-effective, and the results remained cost-effective over the majority of sensitivity analyses. When adopting a broader NHS and PSS perspective, PET-CT management produced an average saving of £700 and had an 81% probability of being cost-effective.

CONCLUSIONS

This analysis indicates that PET-CT-guided management is cost-effective in the long-term and supports the case for wide-scale adoption.

A systematic literature review of health state utility values in head and neck cancer

BACKGROUND

Health state utility values (HSUVs) are essential parameters in model-based economic evaluations. This study systematically identifies HSUVs in head and neck cancer and provides guidance for selecting them from a growing body of health-related quality of life studies.

METHODS

We systematically reviewed the published literature by searching PubMed, EMBASE and The Cochrane Library using a pre-defined combination of keywords. The Tufts Cost-Effectiveness Analysis Registry and the School of Health and Related Research Health Utilities Database (ScHARRHUD) specifically containing health utilities were also queried, in addition to the Health Economics Research Centre database of mapping studies. Studies were considered for inclusion if reporting original HSUVs assessed using established techniques. The characteristics of each study including country, design, sample size, cancer subsite addressed and demographics of responders were summarized narratively using a data extraction form. Quality scoring and critical appraisal of the included studies were performed based on published recommendations.

RESULTS

Of a total 1048 records identified by the search, 28 studies qualified for data extraction and 346 unique HSUVs were retrieved from them. HSUVs were estimated using direct methods (e.g. standard gamble; n = 10 studies), multi-attribute utility instruments (MAUIs; n = 13) and mapping techniques (n = 3); two studies adopted both direct and indirect approaches. Within the MAUIs, the EuroQol 5-dimension questionnaire (EQ-5D) was the most frequently used (n = 11), followed by the Health Utility Index Mark 3 (HUI3; n = 2), the 15D (n = 2) and the Short Form-Six Dimension (SF-6D; n = 1). Different methods and types of responders (i.e. patients, healthy subjects, clinical experts) influenced the magnitude of HSUVs for comparable health states. Only one mapping study developed an original algorithm using head and neck cancer data. The identified studies were considered of intermediate quality.

DISCUSSION

This review provides a dataset of HSUVs systematically retrieved from published studies in head and neck cancer. There is currently a lack of research for some disease phases including recurrent and metastatic cancer, and treatment-related complications. In selecting HSUVs for cost-effectiveness modeling purposes, preference should be given to EQ-5D utility values; however, mapping to EQ-5D is a potentially valuable technique that should be further developed in this cancer population.

Is There a Role for Robotic Surgery in the Treatment of Head and Neck Cancer?

OPINION STATEMENT

Given the potential for long-term toxicities from concurrent chemoradiation, there is great interest in surgery as a primary treatment modality for head and neck cancers, particularly in the younger HPV-positive oropharyngeal cancer patient. Transoral robotic surgery (TORS) has proven to be an effective technique to safely treat oropharyngeal and select supraglottic tumors surgically. Sound, traditional surgical principles are employed using improved endoscopic visualization and precise instrumentation to perform oncologic surgery without the morbidity of transmandibular or transcervical approaches. Although level 1 evidence prospective clinical trials are currently underway for TORS, the literature supports its safety and efficacy based on numerous studies. Currently, prospective randomized trials are underway to provide better evidence for or against TORS in oropharyngeal cancer. Patient selection based on comorbidities, anatomy, and available pathological data is critical in choosing patients for TORS.

Survival and Gastrostomy Prevalence in Patients With Oropharyngeal Cancer Treated With Transoral Robotic Surgery vs Chemoradiotherapy

IMPORTANCE

Treatment of oropharyngeal squamous cell carcinoma (OPSCC) presents unique challenges and can be associated with significant morbidity. Transoral robotic surgery (TORS) has emerged as a treatment modality for OPSCC, but data comparing outcomes between patients treated with TORS-based therapy and nonsurgical therapy are limited.

OBJECTIVE

To compare survival and gastrostomy prevalence between patients with OPSCC treated with TORS-based therapy and those treated with nonsurgical therapy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective matched-cohort study identified patients with OPSCC treated at the University of Washington and University of Minnesota tertiary care medical centers from January 1, 2005, to December 31, 2013. Each patient treated with TORS-based therapy was matched by stage with as many as 3 patients treated with nonsurgical therapy. Final follow-up was completed on April 1, 2015.

MAIN OUTCOMES AND MEASURES

Disease-free survival, overall survival, and gastrostomy tube prevalence.

RESULTS

One hundred twenty-seven patients met the study criteria (113 men [89.0%]; 14 women [11.0%]; median [interquartile range] age, 57 [52-63] years); 39 patients who underwent TORS were matched to 88 patients who underwent nonsurgical therapy. Compared with the nonsurgical group, more patients had p16-positive tumors in the TORS group (30 of 31 [96.8%] vs 30 of 37 [81.1%] among patients with known p16 status). No statistically significant difference in survival between treatment groups was found in multivariable analysis (disease-free survival hazard ratio, 0.22; 95% CI, 0.04-1.36; P = .10). Patients who received TORS-based therapy had lower gastrostomy tube prevalence after treatment (13 of 39 [33.3%] vs 74 of 88 [84.1%]) for a univariable relative risk of 0.43 (95% CI, 0.27-0.67; P < .001) and a multivariable relative risk of 0.43 (95% CI, 0.27-0.68; P < .001). Gastrostomy prevalence decreased by time after treatment for both groups (TORS group: 3 of 34 [9%] at 3 months to 1 of 33 [3%] at 12 months; nonsurgical group: 37 of 82 [45%] at 3 months to 7 of 66 [11%] at 12 months).

CONCLUSIONS AND RELEVANCE

Patients undergoing TORS for OPSCC have statistically indistinguishable survival but lower gastrostomy prevalence compared with patients undergoing nonsurgical therapy for stage-matched OPSCC. TORS offers promise for improved swallowing function in patients with OPSCC.

PET-NECK: a multicentre randomised Phase III non-inferiority trial comparing a positron emission tomography-computerised tomography-guided watch-and-wait policy with planned neck dissection in the management of locally advanced (N2/N3) nodal metastases in patients with squamous cell head and neck cancer

BACKGROUND

Planned neck dissection (ND) after radical chemoradiotherapy (CRT) for locally advanced nodal metastases in patients with head and neck squamous cell carcinoma (HNSCC) remains controversial. Thirty per cent of ND specimens show histological evidence of tumour. Consequently, a significant proportion of clinicians still practise planned ND. Fludeoxyglucose positron emission tomography (PET)-computerised tomography (CT) scanning demonstrated high negative predictive values for persistent nodal disease, providing a possible alternative paradigm to ND. Evidence is sparse and drawn mainly from retrospective single-institution studies, illustrating the need for a prospective randomised controlled trial.

OBJECTIVES

To determine the efficacy and cost-effectiveness of PET-CT-guided surveillance, compared with planned ND, in a multicentre, prospective, randomised setting.

DESIGN

A pragmatic randomised non-inferiority trial comparing PET-CT-guided watch-and-wait policy with the current planned ND policy in HNSCC patients with locally advanced nodal metastases and treated with radical CRT. Patients were randomised in a 1 : 1 ratio. Primary outcomes were overall survival (OS) and cost-effectiveness [incremental cost per incremental quality-adjusted life-year (QALY)]. Cost-effectiveness was assessed over the trial period using individual patient data, and over a lifetime horizon using a decision-analytic model. Secondary outcomes were recurrence in the neck, complication rates and quality of life. The recruitment of 560 patients was planned to detect non-inferior OS in the intervention arm with a 90% power and a type I error of 5%, with non-inferiority defined as having a hazard ratio (HR) of no higher than 1.50. An intention-to-treat analysis was performed by Cox's proportional hazards model.

SETTINGS

Thirty-seven head and neck cancer-treating centres (43 NHS hospitals) throughout the UK.

PARTICIPANTS

Patients with locally advanced nodal metastases of oropharynx, hypopharynx, larynx, oral or occult HNSCC receiving CRT and fit for ND were recruited.

INTERVENTION

Patients randomised to planned ND before or after CRT (control), or CRT followed by fludeoxyglucose PET-CT 10-12 weeks post CRT with ND only if PET-CT showed incomplete or equivocal response of nodal disease (intervention). Balanced by centre, planned ND timing, CRT schedule, disease site and the tumour, node, metastasis stage.

RESULTS

In total, 564 patients were recruited (ND arm, n = 282; and surveillance arm, n = 282; 17% N2a, 61% N2b, 18% N2c and 3% N3). Eighty-four per cent had oropharyngeal cancer. Seventy-five per cent of tested cases were p16 positive. The median time to follow-up was 36 months. The HR for OS was 0.92 [95% confidence interval (CI) 0.65 to 1.32], indicating non-inferiority. The upper limit of the non-inferiority HR margin of 1.50, which was informed by patient advisors to the project, lies at the 99.6 percentile of this estimate (p = 0.004). There were no differences in this result by p16 status. There were 54 NDs performed in the surveillance arm, with 22 surgical complications, and 221 NDs in the ND arm, with 85 complications. Quality-of-life scores were slightly better in the surveillance arm. Compared with planned ND, PET-CT surveillance produced an incremental net health benefit of 0.16 QALYs (95% CI 0.03 to 0.28 QALYs) over the trial period and 0.21 QALYs (95% CI -0.41 to 0.85 QALYs) over the modelled lifetime horizon.

LIMITATIONS

Pragmatic randomised controlled trial with a 36-month median follow-up.

CONCLUSIONS

PET-CT-guided active surveillance showed similar survival outcomes to ND but resulted in considerably fewer NDs, fewer complications and lower costs, supporting its use in routine practice.

FUTURE WORK

PET-CT surveillance is cost-effective in the short term, and long-term cost-effectiveness could be addressed in future work.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13735240.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 17. See the NIHR Journals Library website for further project information.

Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost-effectiveness of transoral robotic surgery (TORS) for the diagnosis and treatment of cervical unknown primary squamous cell carcinoma (CUP).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic hospital.

SUBJECTS AND METHODS

A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with nondiagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Direct costs were obtained from the hospital's billing system, and national data were used for inpatient hospital costs and physician fees. The proportion of tumors found in 3 strategies was used as effectiveness to calculate the incremental cost-effectiveness ratio.

RESULTS

In total, 206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. The primary tumor was located in 19 of 22 patients (86.4%). The incremental cost-effectiveness ratio for sequential and simultaneous examination under anesthesia with tonsillectomy (EUA) and TORS base of tongue resection was $8619 and $5774 per additional primary identified, respectively.

CONCLUSION

Sequential EUA followed by TORS is associated with an incremental cost-effectiveness ratio of $8619 compared with traditional EUA alone. Bilateral base of tongue resection should be considered in the workup of these patients, particularly if the palatine tonsils have already been removed.