Experts Debate Cost-Benefit of Robotic Technology in Head and Neck Cancers
New York, NY—Four head and neck surgeons, 3 of whom use robots in their practice, squared off in a friendly debate on the pros and cons of advanced technology use, focusing on the examples of thyroidectomy and advanced oropharyngeal cancer, at the 2014 American Head and Neck Society annual meeting.
It’s Not about the Money
First at bat was David J. Terris, MD, Porubsky Distinguished Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Georgia Regents University, Augusta. Dr Terris advocated for remote-access thyroidectomy, saying, “This is not about the robot…and it’s not about money. It’s more about patient choice and about enabling innovation. Ultimately, the question is, ‘Should we offer innovative approaches for selected patients, or must we insist that everyone have their surgery done the same way?’”
Dr Terris told Value-Based Cancer Care (VBCC) that “if you look at the demographic of surgeons across the country, it’s dominated by middle-aged men, and those individuals bring their own biases to bear. They often say, ‘I don’t care about a neck scar so I’m not concerned about a neck scar in my patients,’ but we shouldn’t substitute our own biases for our patients’ biases.”
Dr Terris described a study of patient preferences for surgical approach to thyroid surgery, in which 82% of respondents said they preferred remote access thyroidectomy to cervical thyroidectomy, all costs being equal (Coorough NE, et al. World J Surg. 2014;38:696-703). Furthermore, 89% indicated that the scar from surgery was at least “a little” important.
It Is about the Money
David E. Schuller, MD, Vice President, Medical Center Expansion and Outreach, and Chief Executive Officer Emeritus, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Ohio State University, Columbus, countered that if the patients in the study were simply asked whether they would want a scar, “that’s a flawed survey. You need to ask that question, and also inform the patient that to do a procedure that doesn’t leave a noticeable scar, that will mean cost to the patient and the risk of complications that don’t even exist with the standard approach,” he told VBCC. Dr Schuller said that he performed thyroid surgery for 40 years, and “I don’t recall any patient expressing a concern over the possibility of a scar in that region. It also was rare to produce a scar that required scar revision.”
Dr Schuller said that experts in the field should agree on a set of parameters to be used to define the ‘best’ approach to thyroid surgery. He proposed a set of 13 such metrics, including operative time, length of hospital stay, morbidity, mortality, functional benefit, cosmetic benefit, magnitude of societal impact, and total cost. Dr Schuller also echoed a call he made in a 2012 editorial, in which he wrote that it is time “for our journal leaders to consider mandating some type of discussion of cost-effectiveness in every publication proposing a new diagnostic, therapeutic, or preventive innovation” (Arch Otolaryngol Head Neck Surg. 2012;138:539-540).
TORS in Pharyngeal Cancer Less Costly than Radiotherapy
Gregory S. Weinstein, MD, Professor, and Director, Division of Head and Neck Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, sparred civilly about the use of robots for the surgical treatment of oropharyngeal cancer with C. René Leemans, MD, PhD, Chair, Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, Amsterdam, The Netherlands.
“I think the robotic system would have to become considerably less expensive to be cost-effective,” Dr Leemans told VBCC. “When the market opens up—there is only 1 company now, and that drives cost—that may happen.”
Dr Weinstein said that data generated by his team, as well as by researchers at the Mayo Clinic and Johns Hopkins University, indicate that length of hospital stay and the related costs are lower for transoral robotic surgery (TORS) resection of pharyngeal cancer than the combination of chemotherapy and radiation (eg, Richmon JD, et al. Laryngoscope. 2014;124:165-171).
“The assumption that the other alternatives are cheaper than robotic surgery is fallacious,” Dr Weinstein told VBCC. “I’d label those who demand that journals require all ‘new’ procedures to provide cost justification as being ‘therapeutic nihilists’ and anti-innovation. I’m in favor of requiring such scrutiny of all existing approaches, not just the new ones. The alternative standard to TORS with the da Vinci Surgical System is chemoradiation therapy, and this is extremely expensive too.”
Dr Leemans and Dr Weinstein agreed that an ongoing TORS deintensification trial funded by the National Cancer Institute, ECOG 3311, as well as 2 European trials in preparation, should help clarify the cost-benefit equation.