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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wurschi GW. [Neoadjuvant chemotherapy in operable colon cancer: is this a potential new standard?]. Strahlenther Onkol 2024; 200:97-98. [PMID: 37816970 PMCID: PMC10784381 DOI: 10.1007/s00066-023-02161-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/12/2023]
Affiliation(s)
- Georg W Wurschi
- Universitätsklinikum Jena, Klinik für Strahlentherapie und Radioonkologie, Friedrich-Schiller-Universität Jena, 07747, Jena, Deutschland.
- Universitätsklinikum Jena, Interdisziplinäres Zentrum für Klinische Forschung (IZKF), Clinician Scientist-Programm (CSP), Friedrich-Schiller-Universität Jena, 07747, Jena, Deutschland.
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Wurschi GW, Knippen S, Ernst T, Schneider C, Helfritzsch H, Mothes H, Liebe Y, Huber M, Wittig A. Long-Term Total Neoadjuvant Therapy Leads to Impressive Response Rates in Rectal Cancer: Results of a German Single-Center Cohort. Curr Oncol 2023; 30:5366-5378. [PMID: 37366890 DOI: 10.3390/curroncol30060407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/17/2023] [Accepted: 05/27/2023] [Indexed: 06/28/2023] Open
Abstract
Intensified preoperative chemotherapy after (chemo)radiotherapy, (Total Neoadjuvant Therapy-TNT), increases pathological complete response (pCR) rates and local control. In cases of clinically complete response (cCR) and close follow-up, non-operative management (NOM) is feasible. We report early outcomes and toxicities of a long-term TNT regime in a single-center cohort. Fifteen consecutive patients with distal or middle-third locally advanced rectal cancer (UICC stage II-III) were investigated, who received neoadjuvant chemoradiotherapy (total adsorbed dose: 50.4 Gy in 28 fractions and two concomitant courses 5-fluorouracil (250 mg/m2/d)/oxaliplatin (50 mg/m2), followed by consolidating chemotherapy (nine courses of FOLFOX4). NOM was offered if staging revealed cCR 2 months after TNT, with resection performed otherwise. The primary endpoint was complete response (pCR + cCR). Treatment-related side effects were quantified for up two years after TNT. Ten patients achieved cCR, of whom five opted for NOM. Ten patients (five cCR and five non-cCR) underwent surgery, with pCR confirmed in the five patients with cCR. The main toxicities comprised leukocytopenia (13/15), fatigue (12/15) and polyneuropathy (11/15). The most relevant CTC °III + IV events were leukocytopenia (4/15), neutropenia (2/15) and diarrhea (1/15). The long-term TNT regime resulted in promising response rates that are higher than the response rates of short TNT regimes. Overall tolerability and toxicity were comparable with the results of prospective trials.
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Affiliation(s)
- Georg W Wurschi
- Clinician Scientist Program, Interdisciplinary Center for Clinical Research (IZKF), Department of Radiotherapy and Radiation Oncology, Jena University Hospital, 07747 Jena, Germany
| | - Stefan Knippen
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, 07747 Jena, Germany
| | - Thomas Ernst
- University Tumor Center (UTC), Jena University Hospital, 07747 Jena, Germany
| | - Claus Schneider
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, 07747 Jena, Germany
| | - Herry Helfritzsch
- Department of General, Visceral and Thoracic Surgery, Thuringia-Clinic Saalfeld Georgius Agricola, 07318 Saalfeld, Germany
| | - Henning Mothes
- Department of General, Visceral and Vascular Surgery, Sophien-und Hufeland-Klinikum Weimar, 99425 Weimar, Germany
| | - Yves Liebe
- Department of General and Visceral Surgery, SRH Wald-Klinikum Gera, 07548 Gera, Germany
| | - Martin Huber
- Department of General, Visceral and Vascular Surgery, Robert-Koch-Hospital, 99510 Apolda, Germany
| | - Andrea Wittig
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, 07747 Jena, Germany
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Wurschi GW, Güllmar D, Gaßler N, Clement J, Kesselmeier M, Müller-Wurschi JJ, Settmacher U, Mothes H, Helfritzsch H, Liebe Y, Franiel T, Mäurer MA, Ernst T, Nicolay NH, Wittig A. Planning adaptive treatment by longitudinal response assessment implementing MR imaging, liquid biopsy and analysis of microenvironment during neoadjuvant treatment of rectal cancer (PRIMO). Medicine (Baltimore) 2023; 102:e33575. [PMID: 37115093 PMCID: PMC10146036 DOI: 10.1097/md.0000000000033575] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Conducting neoadjuvant chemoradiotherapy (CRT) and additional preoperative consolidating chemotherapy (CTx), that is, total neoadjuvant therapy (TNT), improves local control and complete response (CR) rates in locally advanced rectal cancer (LARC), putting the focus on organ preservation concepts. Therefore, assessing response before surgery is crucial. Some LARC patients would either not benefit from intensification by TNT or may reach CR, making resection not mandatory. Treatment of LARC should therefore be based on patient individual risk and response to avoid overtreatment.The "PRIMO" pilot study aims to determine early response assessment to form a basis for development and validation of a noninvasive response prediction model by a subsequent prospective multicenter trial, which is highly needed for individual, response-driven therapy adaptions. METHODS PRIMO is a prospective observational cohort study including adult patients with LARC receiving neoadjuvant CRT. At least 4 multiparametric magnetic resonance imaging (MRI) scans (diffusion-weighted imaging [DWI] and hypoxia-sensitive sequences) as well as repeated blood samples in order to analyze circulating tumor cells (CTC) and cell-free tumor DNA (ctDNA) are scheduled. Pelvic radiotherapy (RT, 50.4 Gy) will be performed in combination with a 5-fluorouracil/oxaliplatin regimen in all patients (planned: N = 50), succeeded by consolidation CTx (FOLFOX4) if feasible. Additional (immuno)histochemical markers, such as tumor-infiltrating lymphocytes (TIL) and programmed death ligand 1 (PD-L1) status will be analyzed before and after CRT. Routine resection is scheduled subsequently, nonoperative management is offered alternatively in case of clinical CR (cCR).The primary endpoint is pathological response; secondary endpoints comprise longitudinal changes in MRI as well as in CTCs and TIL. These are evaluated for early response prediction during neoadjuvant therapy, in order to develop a noninvasive response prediction model for subsequent analyses. DISCUSSION Early response assessment is the key in differentiating "good" and "bad" responders during neoadjuvant CRT, allowing adaption of subsequent therapies (additional consolidating CTx, organ preservation). This study will contribute in this regard, by advancing MR imaging and substantiating new surrogate markers. Adaptive treatment strategies might build on these results in further studies.
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Affiliation(s)
- Georg W. Wurschi
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
- Clinician Scientist Program, Interdisciplinary Center for Clinical Research (IZKF), Jena University Hospital, Jena, Germany
| | - Daniel Güllmar
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology (IDIR), Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Nikolaus Gaßler
- Section of Pathology, Institute of Forensic Medicine, Jena University Hospital, Jena, Germany
| | - Joachim Clement
- Department of Hematology and Medical Oncology, Jena University Hospital, Jena, Germany
| | - Miriam Kesselmeier
- Institute of Medical Statistics, Computer and Data Sciences (IMSID), Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
| | | | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - Henning Mothes
- Department of General, Visceral and Vascular Surgery, Sophien- und Hufeland-Klinikum Weimar, Weimar, Germany
| | - Herry Helfritzsch
- Department of General, Visceral and Thoracic Surgery, Thuringia-Clinic Saalfeld Georgius Agricola, Saalfeld, Germany
| | - Yves Liebe
- Department of General and Visceral Surgery, SRH Klinikum Burgenlandkreis Naumburg, Naumburg, Germany
| | - Tobias Franiel
- Institute of Diagnostic and Interventional Radiology (IDIR), Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
| | - Matthias A. Mäurer
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
- Clinician Scientist Program, Interdisciplinary Center for Clinical Research (IZKF), Jena University Hospital, Jena, Germany
| | - Thomas Ernst
- University Tumor Center (UTC), Jena University Hospital, Jena, Germany
| | - Nils H. Nicolay
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - Andrea Wittig
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany
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Wurschi GW, Wittig A. [Good treatment tolerability and quality of life after primary organ-preserving therapy of early-stage rectal cancer: results of the TREC study]. Strahlenther Onkol 2023; 199:601-603. [PMID: 37085725 DOI: 10.1007/s00066-023-02079-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/23/2023]
Affiliation(s)
- Georg W Wurschi
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Jena, Jena, Deutschland.
- Clinician Scientist Programm, Interdisziplinäres Zentrum für Klinische Forschung, Universitätsklinikum Jena, Jena, Deutschland.
| | - Andrea Wittig
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Jena, Jena, Deutschland
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Wurschi GW, Mentzel HJ, Herrmann KH, Krumbein I, Beck JF, Reichenbach JR, Kentouche K. MRI as an alternative to serum ferritin for diagnosis of iron overload in children in the context of immune response after stem cell transplantation. Pediatr Transplant 2019; 23:e13583. [PMID: 31535426 DOI: 10.1111/petr.13583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/18/2019] [Accepted: 08/07/2019] [Indexed: 12/30/2022]
Abstract
Multiple blood cell transfusions may cause iron overload or even liver fibrosis, requiring early diagnosis and intervention. SF is the standard for estimating iron levels in the body, but it also increases with inflammation. We hypothesized that T2 * magnetic resonance (MR) relaxometry is a more accurate alternative for follow-up in pediatric patients before and after allogenic SCT. Twenty-three children (mean age 10.2 years, 10 female, 13 male) were evaluated prospectively before SCT as well as at least 1 year after SCT with T2 * relaxometry on a 1.5 T MR-scanner to estimate liver iron concentrations from the T2 * values ("MR-Fe"). The results were compared with SF, while also considering CRP, and correlated with the number of transfusions. Overall, 24.3 transfusions were administered in average, mainly within 100 days of SCT (mean 10.5 units). Both MR-Fe and SF increased after SCT and decreased in the absence of new transfusions 1 year later without chelate therapy. This suggests regeneration of LP and iron loss, although the original states were not reached. Additionally, simultaneous peaks of CRP and SF were observed directly after SCT. MR-Fe did neither reveal these peaks nor was it associated with CRP (P = .39). We postulate that these early CRP and SF peaks after SCT are probably related to inflammatory reactions and not to iron overload. Thus, SF is not reliable for iron overload diagnosis after SCT in every condition. Beside this interaction, SF and MR-Fe revealed similar accuracy. MRI, however, has practical and economical disadvantages in routine estimation of iron.
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Affiliation(s)
- Georg W Wurschi
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Karl-Heinz Herrmann
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Ines Krumbein
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - James F Beck
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Juergen R Reichenbach
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Karim Kentouche
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Jena, Friedrich Schiller University, Jena, Germany
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