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Wurschi GW, Rühle A, Domschikowski J, Trommer M, Ferdinandus S, Becker JN, Boeke S, Sonnhoff M, Fink CA, Käsmann L, Schneider M, Bockelmann E, Krug D, Nicolay NH, Fabian A, Pietschmann K. Patient-Relevant Costs for Organ Preservation versus Radical Resection in Locally Advanced Rectal Cancer. Cancers (Basel) 2024; 16:1281. [PMID: 38610958 PMCID: PMC11011197 DOI: 10.3390/cancers16071281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Total neoadjuvant therapy (TNT) is an evolving treatment schedule for locally advanced rectal cancer (LARC), allowing for organ preservation in a relevant number of patients in the case of complete response. Patients who undergo this so-called "watch and wait" approach are likely to benefit regarding their quality of life (QoL), especially if definitive ostomy could be avoided. In this work, we performed the first cost-effectiveness analysis from the patient perspective to compare costs for TNT with radical resection after neoadjuvant chemoradiation (CRT) in the German health care system. Individual costs for patients insured with a statutory health insurance were calculated with a Markov microsimulation. A subgroup analysis from the prospective "FinTox" trial was used to calibrate the model's parameters. We found that TNT was less expensive (-1540 EUR) and simultaneously resulted in a better QoL (+0.64 QALYs) during treatment and 5-year follow-up. The average cost for patients under TNT was 4711 EUR per year, which was equivalent to 3.2% of the net household income. CRT followed by resection resulted in higher overall costs for ostomy care, medication and greater loss of earnings. Overall, TNT appeared to be more efficacious and cost-effective from a patient's point of view in the German health care system.
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Affiliation(s)
- Georg W. Wurschi
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, 07747 Jena, Germany;
- Clinician Scientist Program, Interdisciplinary Center for Clinical Research (IZKF), Jena University Hospital, 07747 Jena, Germany
- Cancer Center Central Germany (CCCG), 07747 Jena, Germany
| | - Alexander Rühle
- Department of Radiation Oncology, University of Freiburg—Medical Center, 79106 Freiburg, Germany
- Department of Radiation Oncology, University of Leipzig Medical Center, 04103 Leipzig, Germany
- Cancer Center Central Germany (CCCG), 04103 Leipzig, Germany
| | - Justus Domschikowski
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany (A.F.)
| | - Maike Trommer
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, 50937 Cologne, Germany
- Center for Molecular Medicine Cologne, University of Cologne, 50931 Cologne, Germany
| | - Simone Ferdinandus
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, 50937 Cologne, Germany
- Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Düsseldorf (CIO ABCD), 50937 Cologne, Germany
| | - Jan-Niklas Becker
- Department of Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Simon Boeke
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Mathias Sonnhoff
- Department of Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
- Center for Radiotherapy and Radiation Oncology, 28239 Bremen, Germany
| | - Christoph A. Fink
- Department of Radiation Oncology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Lukas Käsmann
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377 Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 81377 Munich, Germany
| | - Melanie Schneider
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, 01307 Dresden, Germany
| | - Elodie Bockelmann
- Department of Radiotherapy and Radiation Oncology, University Hospital Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany (A.F.)
| | - Nils H. Nicolay
- Department of Radiation Oncology, University of Leipzig Medical Center, 04103 Leipzig, Germany
- Cancer Center Central Germany (CCCG), 04103 Leipzig, Germany
| | - Alexander Fabian
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany (A.F.)
| | - Klaus Pietschmann
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, 07747 Jena, Germany;
- Cancer Center Central Germany (CCCG), 07747 Jena, Germany
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Bibi S, Edilbe MW, Rao C. The Cost-effectiveness of Watch and Wait for Rectal Cancer. Clin Oncol (R Coll Radiol) 2023; 35:132-137. [PMID: 36266161 DOI: 10.1016/j.clon.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/25/2022] [Accepted: 10/03/2022] [Indexed: 01/18/2023]
Abstract
The existing literature suggests with a high degree of certainty that watch and wait is more cost-effective than initial total mesorectal excision. However, it is heavily reliant on poor-quality health-related quality of life data. Furthermore, the cost-effectiveness of organ preservation from a broader societal perspective has not been studied. Finally, the cost-effectiveness of emerging adjuncts to watch and wait for organ preservation, such as contact X-ray brachytherapy, local excision and total neoadjuvant therapy, need to be characterised.
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Affiliation(s)
- S Bibi
- The Department of Colorectal Surgery, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - M W Edilbe
- The Department of Colorectal Surgery, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK; The Academic Surgical Unit, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - C Rao
- The Academic Surgical Unit, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK; The Department of Surgery and Cancer, Imperial College, London, UK.
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Grabenbauer A, Aigner T, Göbel H, Leibl BJ, Lamberti C, Grabenbauer GG, Distel LV. Preoperative Radiochemotherapy in Rectal Cancer: Is There an Impact of Oxaliplatin on Pathologic Complete Response and Survival Rates under "Real World" Conditions? Cells 2023; 12:cells12030399. [PMID: 36766741 PMCID: PMC9913152 DOI: 10.3390/cells12030399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
This study aimed to evaluate the benefit of additional administration of oxaliplatin during fluorouracil-based neoadjuvant radiochemotherapy (nRCT) in terms of pathologic complete remission (pCR), disease-free survival (DFS), and overall survival (OS) in patients with advanced rectal cancer. Between 2006 and 2021, 669 patients (pts) were diagnosed with locally advanced rectal cancer, of whom a total of 414 pts with nRCT were identified and included in the study. A total of 283 pts were treated by nRCT using concurrent chemotherapy with fluorouracil or capecitabine; 131 pts were treated using a combination of fluorouracil or capecitabine and oxaliplatin. Propensity score matching analyses (PSM) with 114 pts in each group were used to balance the patients' characteristics. OS, DFS, pCR-rate, and potential prognostic factors were compared between the two groups. The median follow-up time was 59.5 weeks in the fluorouracil-group and 43 weeks in the fluorouracil/oxaliplatin group (p = 0.003). After PSM, the pCR-rate (including sustained clinical complete remission) was 27% (31/114 pts) in the fluorouracil/oxaliplatin group and 16% (18/114 pts) in the fluorouracil-group (p = 0.033). There was no difference between these two groups for both 10-year OS and DFS neither before nor after PSM, respectively (OS: 72.6% vs. 55.4%, p = 0.066, and 67.8% vs. 55.1%, p = 0.703, and DFS: 44.8% vs. 46.8%, p = 0.134, and 44.7% vs. 42.3%, p = 0.184). Multivariate analysis identified regression grading according to Dworak grade 4 (HR: 0.659; CI: 0.471-0.921; p = 0.015) and age over 60 years (HR: 2.231; CI: 1.245-4.001; p = 0.007) as independent predictors for OS. In conclusion, the addition of oxaliplatin to fluorouracil during nRCT significantly improved pCR-rate without having an impact on survival.
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Affiliation(s)
- Alexander Grabenbauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Thomas Aigner
- Department of Pathology, Coburg Cancer Center, 96450 Coburg, Germany
| | - Holger Göbel
- Department of Gastroenterology, Coburg Cancer Center, 96450 Coburg, Germany
| | - Bernhard J. Leibl
- Department of Abdominal Surgery, Coburg Cancer Center, 96450 Coburg, Germany
| | - Christof Lamberti
- Department of Hematology and Oncology, Coburg Cancer Center, 96450 Coburg, Germany
| | | | - Luitpold V. Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
- Correspondence: ; Tel.: +49-9131-853-2312; Fax: +49-9131-853-9335
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Anker CJ, Akselrod D, Ades S, Bianchi NA, Lester-Coll NH, Cataldo PA. Non-operative Management (NOM) of Rectal Cancer: Literature Review and Translation of Evidence into Practice. CURRENT COLORECTAL CANCER REPORTS 2021. [DOI: 10.1007/s11888-020-00463-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kuncman Ł, Stawiski K, Masłowski M, Kucharz J, Fijuth J. Dose-volume parameters of MRI-based active bone marrow predict hematologic toxicity of chemoradiotherapy for rectal cancer. Strahlenther Onkol 2020; 196:998-1005. [PMID: 32621010 PMCID: PMC7653786 DOI: 10.1007/s00066-020-01659-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 06/13/2020] [Indexed: 01/22/2023]
Abstract
Purpose Magnetic resonance imaging (MRI) is routinely used for locoregional staging of rectal cancer and offers promise for the prediction of hematologic toxicity. The present study compares the clinical utility of MRI-based active bone marrow (BMact) delineation with that of CT-based bone marrow total (BMtot) delineation for predicting hematologic toxicity. Methods A prospective cohort study was performed. Eligible patients had stage II/III rectal cancer and qualified for preoperative chemoradiotherapy. The BMact areas on T1-weighted MRI were contoured. The impact of the dose–volume parameters of BMact/BMtot and clinical data on hematologic toxicity were assessed. Basic endpoints were the occurrence of grade 3/4 hematologic toxicity and peripheral blood parameters reaching a nadir. Linear regression models were generated for the nadirs and receiver operating characteristic (ROC) curves for the occurrence of grade 3/4 hematologic toxicity. Results Thirty-five patients were enrolled. Women presented higher dose–volume parameters of BMact, BMtot, and lymphocyte nadir (ALCnadir%) than men. Models for the prediction of ALCnadir% (V5-V20BMtot, V5-V30BMact) and platelet nadir (PLTnadir%; V5-V10BMtot, V5-V20BMact) were statistically significant. In the ROC curves, a baseline lymphocyte level of 1.81 × 103/ml was adopted as the cutoff for predicting grade 3/4 lymphopenia, with specificity of 77.8% and sensitivity of 73.1%. The multivariate linear regression model for ALCnadir% had R2 = 0.53, p = 0.038. In the tenth step of selection, V5BMact (p = 0.002) and gender (p = 0.019) remained. The multivariate linear regression model for PLTnadir% had R2 = 0.20, p = 0.34. In the sixth step of selection, V15BMact remained (p = 0.026). Conclusion The dose–volume parameters of BMact serve as better predictors of ALCnadir% and PLTnadir% than BMtot.
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Affiliation(s)
- Łukasz Kuncman
- Department of Radiotherapy, Medical University of Lodz, Zakład Radioterapii, W.W.C.O.iT. im. M. Kopernika w Łodzi, Pabianicka 62 street, 93-513, Łódź, Poland. .,Department of External Beam Radiotherapy, Regional Cancer Center, Copernicus Memorial Hospital of Lodz, Zakład Teleradioterapii, Wojewódzkie W.W.C.O.iT. im. M. Kopernika w Łodzi, Pabianicka 62 street, 93-513, Łódź, Poland.
| | - Konrad Stawiski
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Zakład Biostatystyki i Medycyny Translacyjnej, Cenrum Mazowiecka 15 street, 92-215, Łódź, Poland
| | - Michał Masłowski
- Department of External Beam Radiotherapy, Regional Cancer Center, Copernicus Memorial Hospital of Lodz, Zakład Teleradioterapii, Wojewódzkie W.W.C.O.iT. im. M. Kopernika w Łodzi, Pabianicka 62 street, 93-513, Łódź, Poland
| | - Jakub Kucharz
- Department of Uro-Oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology Warsaw, Klinika Nowotworów Układu Moczowego, Centrum Onkologii-Instytut im. Marii Skłodowskiej-Curie ul. Roentgena 5, 02-781, Warszawa, Poland
| | - Jacek Fijuth
- Department of Radiotherapy, Medical University of Lodz, Zakład Radioterapii, W.W.C.O.iT. im. M. Kopernika w Łodzi, Pabianicka 62 street, 93-513, Łódź, Poland.,Department of External Beam Radiotherapy, Regional Cancer Center, Copernicus Memorial Hospital of Lodz, Zakład Teleradioterapii, Wojewódzkie W.W.C.O.iT. im. M. Kopernika w Łodzi, Pabianicka 62 street, 93-513, Łódź, Poland
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Oncological Outcomes and Hospital Costs of the Treatment in Patients With Rectal Cancer: Watch-and-Wait Policy and Standard Surgical Treatment. Dis Colon Rectum 2020; 63:598-605. [PMID: 32032202 DOI: 10.1097/dcr.0000000000001594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Little is known about the costs of the current treatment strategy in locally advanced rectal cancer, in which patients with a clinical complete response after chemoradiotherapy are treated in a watch-and-wait policy. OBJECTIVE The aim of this study is to present the oncological outcome and hospital costs of patients with a complete response after chemoradiotherapy (watch-and-wait policy) and patients with an incomplete response after chemoradiotherapy (total mesorectal excision). DESIGN This was a cohort study. SETTINGS This study was conducted at an academic and a nonacademic hospital. PATIENTS Patients with locally advanced rectal cancer received either a watch-and-wait policy or total mesorectal excision depending on their clinical response to chemoradiotherapy. INTERVENTIONS Watch-and-wait policy and total mesorectal excision were the treatments applied. MAIN OUTCOME MEASURES The primary outcomes measured were overall, local recurrence-free, and distant metastasis-free survival and hospital costs over a 2-year follow-up period. RESULTS A total of 292 patients with locally advanced rectal cancer were included. Mean age was 65.1 years, and 64.7% were men. One hundred five patients were included in the watch-and-wait subgroup, and 187 patients were in the total mesorectal excision subgroup. Both subgroups showed good oncological outcomes. Hospital costs consisted of 5 categories: costs of primary surgery, costs of adjuvant chemotherapy, costs of examinations, costs of additional surgery, and costs of treatment of regrowth/metastasis. The mean costs per patient were &OV0556;6713 (watch-and-wait subgroup) and &OV0556;17,108 (total mesorectal excision subgroup) over the first 2 years. LIMITATIONS This study was limited by the following: costs were only from a hospital perspective, follow-up was 2 years, the study was retrospective in part, and there was no comparative study. CONCLUSIONS Overall survival was good in both subgroups and comparable to literature. The mean costs per patient differ between the watch-and-wait subgroup (&OV0556;6713) and the total mesorectal excision subgroup (&OV0556;17,108). No comparison between the groups could be made. Based on the results of this study, the current strategy, where patients with a clinical complete response are treated in a watch-and-wait policy, and patients with an incomplete response are treated with total mesorectal excision, is likely to be (cost)saving. See Video Abstract at http://links.lww.com/DCR/B177. RESULTADOS ONCOLÓGICOS Y COSTOS HOSPITALARIOS EN EL TRATAMIENTO DE PACIENTES CON CANCER DE RECTO: ACTITUD DE ESPERA-VIGILANCIA Y TRATAMIENTO QUIRÚRGICO ESTANDARD: Se sabe poco sobre el costo del tratamiento actual en casos de cancer de recto localmente avanzado, cuando se aplica una política de vigilancia y espera en aquellos pacientes que presentan una respuesta clínica completa después de radio-quimioterapia.El propósito final del presente estudio es dar a conocer el resultado oncológico y los costos hospitalarios de los pacientes que presentan una respuesta clínica completa después de radio-quimioterapia (actitud de vigilancia-espera) y los pacientes con una respuesta incompleta después luego de radio-quimioterapia (excisión total del mesorrecto-ETM).Estudio de cohortes.Hospitales académicos y no académicos.Todos aquellos pacientes tratados por un cáncer de recto localmente avanzado y que fueron seguidos con una política de vigilancia y espera o la ETM, en función de la respuesta clínica a la radio-quimioterapia.Políticas de vigilancia-espera, excisión total del mesorrecto.Sobrevida global libre de recurrencia local, metástasis a distancia, sobrevida libre de enfermedad y costos hospitalarios durante un período de seguimiento de dos años.Se incluyeron 292 pacientes diagnosticados de cancer de recto localmente avanzado. La edad media fue de 65,1 años, 64,7% eran de sexo masculino. Se incluyeron 105 pacientes en el subgrupo de vigilancia-espera, y 187 en el subgrupo de excisión total del mesorrecto. Ambos subgrupos mostraron optimos resultados oncológicos. Los costos hospitalarios se dividieron en cinco categorías: costos de cirugía primaria; costos de quimioterapia adyuvante; costos de exámenes; costos de cirugía adicional; y costos del tratamiento de rebrote / metástasis. Los costos medios por paciente fueron de &OV0556; 6.713 (subgrupo de espera-vigilancia) y &OV0556; 17.108 (subgrupo de excisión total del mesorrecto) durante los primeros dos años.Analisis de costos desde una perspectiva hospitalaria durante un seguimiento de dos años, estudio parcialmente retrospectivo, no comparativo.La sobrevida general fue optima en ambos subgrupos y comparable con la literatura. El costo promedio por paciente difiere entre el subgrupo de vigilancia y espera (&OV0556; 6.713) con el subgrupo de la ETM(&OV0556; 17.108). No se pudieron comparar definitivamente ambos grupos. Basados en los resultados del presente estudio, es probable que la estrategia actual, en la que los pacientes con respuesta clínica completa sean tratados con una política de vigilancia y espera, presenten muy probablemente un cierto ahorro en el costo con relación a los pacientes con una respuesta incompleta tratados con excisión total del mesorrecto. Consulte Video Resumen en http://links.lww.com/DCR/B177. (Traducción-Dr. Xavier Delgadillo).
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