Cost-effectiveness of neoadjuvant concurrent chemoradiotherapy versus esophagectomy for locally advanced esophageal squamous cell carcinoma: A population-based matched case-control study

Abstract

Background: Neoadjuvant concurrent chemoradiotherapy (NCCRT) is often considered for locally-advanced esophageal squamous cell carcinoma (LA-ESCC) patients; however, no data regarding the cost-effectiveness of this treatment is available. Our study aimed to evaluate the cost-effectiveness of NCCRT versus esophagectomy for LA-ESCC at population level.

Methods: We identified LA-ESCC patients diagnosed within 2008-2009 and treated with either NCCRT or esophagectomy through the Taiwan Cancer Registry. We included potential confounding covariables (age, gender, residency, comorbidity, social-economic status, disease stage, treating hospital level and surgeon's experience, and the use of endoscopic ultrasound before treatment) and used propensity score (PS) to construct a 1:1 population. The duration of interest was three years within the date of diagnosis. Effectiveness was measured as overall survival. We took the payer's perspective and converted the cost to 2014 United States dollars (USD). In sensitivity analysis, we evaluated the potential impact of an unmeasured confounder on the statistical significance of incremental net benefit at suggested willingness-to-pay.

Results: Our study population constituted 150 PS matched subjects. The mean cost (2014 USD) and survival (year) were higher for NCCRT compared with esophagectomy (US$91,460 vs. $75,836 for cost; 2.2 vs. 1.8 for survival) with an estimated incremental cost-effectiveness ratio of US$39,060/life-year.

Conclusions: When compared to esophagectomy, NCCRT is likely to improve survival and is probably more cost-effective. Cost-effectiveness results should be interpreted with caution given our results were sensitive to potential unmeasured confounder(s) in sensitivity analysis.

Keywords: Cost‐effectiveness analysis; Taiwan; esophageal squamous cell carcinoma; neoadjuvant concurrent chemoradiotherapy; propensity‐score matching.

Figure 1

Study flow chart. ¹: We only included patients treated by any single institution to ensure data consistency. ²: 6^th American Joint Committee on Cancer staging cT2‐3N0M0 or cT1‐3N1M0. ³: We only included patients who had visited a single surgeon (among those diagnosed 2008–2009 who had received esophagectomy for esophageal cancer before NCCRT or esophagectomy. ⁴: Income higher than minimal wage. ⁵: Hospitals were classified as medical center or regional hospital; surgeons were classified as high (had performed at least 28 esophagectomies for esophageal cancer for those diagnosed 2008–2009) or low volume.

Figure 2

Kaplan–Meier survival curve (NCCRT vs. esophagectomy, in days). nccrt = 1 (dotted line) for neoadjuvant concurrent chemoradiotherapy; nccrt = 0 (solid line) for esophagectomy.

Figure 3

Cost‐effectiveness acceptability curve. Vertical axis: probability of neoadjuvant concurrent chemoradiotherapy (NCCRT) to be associated with positive net benefit. Horizontal axis: willingness‐to‐pay (WTP). LY, life‐year; USD, United States dollars.