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Avoiding Radical Surgery in Elderly Patients With Rectal Cancer Is Cost-Effective

Rao, Christopher, M.R.C.S., Ph.D.; Sun Myint, Arthur, F.R.C.R.; Athanasiou, Thanos, F.R.C.S., Ph.D.; Faiz, Omar, F.R.C.S., Ph.D.; Martin, Antony Paul, M.Sc.; Collins, Brendan, Ph.D.; Smith, Fraser McLean, F.R.C.S.I., M.D.

Diseases of the Colon & Rectum: January 2017 - Volume 60 - Issue 1 - p 30–42
doi: 10.1097/DCR.0000000000000708
Original Contributions: Colorectal/Anal Neoplasia

BACKGROUND: Radical surgery is associated with significant perioperative mortality in elderly and comorbid populations. Emerging data suggest for patients with a clinical complete response after neoadjuvant chemoradiotherapy that a watch-and-wait approach may provide equivalent survival and oncological outcomes.

OBJECTIVE: The purpose of this study was to compare the cost-effectiveness of watch and wait and radical surgery for patients with rectal cancer after a clinical complete response following chemoradiotherapy.

DESIGN: Decision analytical modeling and a Markov simulation were used to model long-term costs, quality-adjusted life-years, and cost-effectiveness after watch and wait and radical surgery. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters.

SETTINGS: A third-party payer perspective was adopted.

PATIENTS: Patients included in the study were a 60-year–old male cohort with no comorbidities, 80-year–old male cohorts with no comorbidities, and 80-year–old male cohorts with significant comorbidities.

INTERVENTIONS: Radical surgery and watch-and-wait approaches were studied.

MAIN OUTCOME MEASURES: Incremental cost, effectiveness, and cost-effectiveness ratio over the entire lifetime of the hypothetical patient cohorts were measured.

RESULTS: Watch and wait was more effective (60-year–old male cohort with no comorbidities = 0.63 quality-adjusted life-years (95% CI, 2.48–3.65 quality-adjusted life-years); 80-year–old male cohort with no comorbidities = 0.56 quality-adjusted life-years (95% CI, 0.52–1.59 quality-adjusted life-years); 80-year–old male cohort with significant comorbidities = 0.72 quality-adjusted life-years (95% CI, 0.34–1.76 quality-adjusted life-years)) and less costly (60-year–old male cohort with no comorbidities = $11,332.35 (95% CI, $668.50–$23,970.20); 80-year–old male cohort with no comorbidities = $8783.93 (95% CI, $2504.26–$21,900.66); 80-year–old male cohort with significant comorbidities = $10,206.01 (95% CI, $2762.014–$24,135.31)) independent of patient cohort age and comorbidity. Consequently, watch and wait was more cost-effective with a high degree of certainty (range, 69.6%–89.2%) at a threshold of $50,000/quality-adjusted life-year.

LIMITATIONS: Long-term outcomes were derived from modeled cohorts. Analysis was performed for a United Kingdom third-party payer perspective, limiting generalizability to other healthcare contexts.

CONCLUSIONS: Watch and wait is likely to be cost-effective compared with radical surgery. These findings strongly support the discussion of organ-preserving strategies with suitable patients.

1 University Hospital Lewisham, London, United Kingdom

2 Clatterbridge Cancer Centre, Merseyside, United Kingdom

3 Department of Surgery and Cancer, Imperial College London, London, United Kingdom

4 Epidemiology, Trials and Outcome Centre, St. Mark’s Hospital, Harrow, United Kingdom

5 National Institute for Health Research, Collaborations for Leadership in Applied Health Research and Care, North West Coast, University of Liverpool, Liverpool, United Kingdom

6 Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom

7 Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom

Funding/Support: Mr Martin was supported by the National Institutes of Health Research Collaboration for Leadership in Applied Health Research and Care North West Coast.

Financial Disclosure: None reported.

Presented at the meeting of the Association of Coloproctology of Great Britain and Ireland, Edinburgh, United Kingdom, July 4 to 6, 2016.

Corresponding Author: Christopher Rao, M.R.C.S., Ph.D., Department of Colorectal Surgery, University Hospital Lewisham, High Street, London SE13 6LH, United Kingdom. E-mail:

© 2017 The American Society of Colon and Rectal Surgeons