For Pancreatic Cancer, Neoadjuvant Chemoradiation Cost-Effective Compared with Surgery First
San Francisco, CA—For resectable pancreatic cancer, administering chemo – therapy and radiation before surgery results in better outcomes and lower costs than performing surgery first, reported researchers from M.D. Anderson Cancer Center, Houston. "Compared with a surgery-first approach, the neoadjuvant approach eliminates an ineffectual, costly, and potentially morbid treatment in patients with early metastases or a prohibitive function status. It is associated with improved survival, and it costs less per patient," said lead investigator Daniel Erik Abbott, MD. "So, as a rule we generally recommend neoadjuvant treatment now." Multimodality therapy for resectable pancreatic head adenocarcinoma provides the best chance for prolonged survival, but because of a lack of randomized data, the optimal sequence of surgery, chemotherapy, and radiation therapy has not been clear. "With fiscal realities increasingly impacting healthcare, cost should be considered when making treatment decisions," he said. Dr Abbott and colleagues, therefore, conducted this study to compare the cost and outcomes of a surgery-first approach versus chemoradiation first followed by surgery.
They constructed a decision model to contrast the 2 strategies, using literature and databases to estimate outcomes in the surgery-first arm, in cluding operative outcomes, complications rates, pathologic stage, adjuvant therapy, and stage-specific survival. The outcomes of "highperforming centers" populated the surgery-first model. Data from a prospectively maintained pancreatic cancer database populated the neoadjuvant arm, who received gemcitabine- or capecitabinebased regimens. Based on Medicare reimbursement, cost (in 2011 dollars) included technical or professional fees and hospital reimbursements. It did not include preoperative work-up procedures, because these were assumed to have been completed for the diagnosis to be made. Survival, discounted when appropriate, was reported in quality-adjusted life-months (QALMs). A 1-way sensitivity analysis was based on the rates of perioperative mortality, complications, and unresectability; costs of adjuvant chemotherapy; radiation therapy practices; and reimbursement for complications (Table).
Clinical outcomes, Cost-Effectiveness
A total of 164 patients completed neoadjuvant chemoradiation. Of these, 22% did not proceed to surgery because of metastasis, poor performance status, or patient choice, or because unresectability was determined at laparotomy. Definitive surgical resection was possible for 116 patients (77%). The surgery-first approach cost $95,781 to yield a survival of 8.7 QALMs, whereas the neoadjuvant strategy cost $71,416 to achieve 18.8 QALMs. In the intent-to-treat neoadjuvant population, which included patients not undergoing surgery, those with unresectable cancer at laparotomy, and those completing surgery, the respective costs were $12,401 to yield 7.7 QALMs, $39,112 to yield 7.1 QALMs, and $92,887 to yield 23.4 QALMs, respectively. "Under no circumstances does cost or effectiveness for surgery first even approximate that achieved with neoadjuvant CRT," he said. "Neo adjuvant chemoradiation should be more widely used as a cost-effective treatment strategy for resectable pancreatic head adenocarcinoma."