The Role of Surgical Resection in Stage IIIA Non-Small Cell Lung Cancer: A Decision and Cost-Effectiveness Analysis

Abstract

Background: This study evaluated the cost-effectiveness of combination chemotherapy, radiotherapy, and surgical intervention (CRS) vs definitive chemotherapy and radiotherapy (CR) in clinical stage IIIA non-small cell lung cancer (NSCLC) patients at academic and nonacademic centers.

Methods: Patients with clinical stage IIIA NSCLC receiving CR or CRS from 1998 to 2010 were identified in the National Cancer Data Base. Propensity score matching on patient, tumor, and treatment characteristics was performed. Medicare allowable charges were used for treatment costs. The incremental cost-effectiveness ratio (ICER) was based on probabilistic 5-year survival and calculated as cost per life-year gained.

Results: We identified 5,265 CR and CRS matched patient pairs. Surgical resection imparted an increased effectiveness of 0.83 life-years, with an ICER of $17,618. Among nonacademic centers, 1,634 matched CR and CRS patients demonstrated a benefit with surgical resection of 0.86 life-years gained, for an ICER of $17,124. At academic centers, 3,201 matched CR and CRS patients had increased survival of 0.81 life-years with surgical resection, for an ICER of $18,144. Finally, 3,713 CRS patients were matched between academic and nonacademic centers. Academic center surgical patients had an increased effectiveness of 1.5 months gained and dominated the model with lower surgical cost estimates associated with lower 30-day mortality rates.

Conclusions: In stage IIIA NSCLC, the selective addition of surgical resection to CR is cost-effective compared with definitive chemoradiation therapy at nonacademic and academic centers. These conclusions are valid over a range of clinically meaningful variations in cost and treatment outcomes.

Figure 1

Consort diagram demonstrating patient selection criteria and propensity matched analysis. *CR and CRS patients were matched on age, gender, race, income, rural versus urban status, year of diagnosis, Charlson Deyo score, tumor size, and facility type (academic versus nonacademic). † Subgroup analyses with academic and nonacademic CR and CRS patients were matched on age, gender, race, income, rural versus urban status, year of diagnosis, Charlson Deyo score, and tumor size.

Figure 2

Two-way sensitivity analysis varying the probability surgical survival after pulmonary resection in Stage IIIA NSCLC from 88–98% and the cost of 30-day hospitalization charges from $50,000 to $250,000. Willingness to pay was set at a conventional threshold of $50,000. For propensity matched CR and CRS patients, the 30-day mortality rate was 2.2%, and the base cost of 30-day mortality was $55,513. This figure indicates that even with decreases in 30-day surgical survival and associated costs, CRS (denoted in red) dominates the decision model over CR for these clinical variations.

Figure 3

Cost-effectiveness acceptability curve with a willingness-to-pay threshold varying from 0 to $50,000. 1000 iterations of CR versus CRS for propensity matched Stage IIIA NSCLC patients were run in a Monte Carlo simulation, using survival inputs from the NCDB and Medicare allowable costs. At a willingness-to-pay threshold of $18,000, surgery begins to dominate the model choices. At a willingness-to-pay threshold of $25,000, 100% of model patient simulations favor CRS over CR.