Annals of Surgical Oncology

, Volume 20, Supplement 3, pp 500–508

The Cost-Effectiveness of Neoadjuvant Chemoradiation is Superior to a Surgery-First Approach in the Treatment of Pancreatic Head Adenocarcinoma

  • Daniel E. Abbott
  • Ching-Wei David Tzeng
  • Ryan P. Merkow
  • Scott B. Cantor
  • George J. Chang
  • Matthew Harold Katz
  • David J. Bentrem
  • Karl Y. Bilimoria
  • Christopher H. Crane
  • Gauri R. Varadhachary
  • James L. Abbruzzese
  • Robert A. Wolff
  • Jeffrey E. Lee
  • Douglas B. Evans
  • Jason B. Fleming
Translational Research and Biomarkers

DOI: 10.1245/s10434-013-2882-0

Cite this article as:
Abbott, D.E., Tzeng, C.D., Merkow, R.P. et al. Ann Surg Oncol (2013) 20: 500. doi:10.1245/s10434-013-2882-0

Abstract

Background

In treating pancreatic cancer, there is no clearly defined optimal sequence of chemotherapy, radiation therapy and surgery. Therefore, cost-effectiveness should be considered. The objective of this study was to compare cost and outcomes between a surgery-first approach versus neoadjuvant chemoradiation followed by surgery for resectable pancreatic head cancer.

Methods

A decision analytic model was constructed to compare the 2 approaches. Data from the National Cancer Database, National Surgical Quality Improvement Program, and literature populated the surgery-first arm. Data from our prospectively maintained institutional pancreatic cancer database populated the neoadjuvant arm. Costs were estimated by Medicare payment (2011 U.S. dollars). Survival was reported in quality-adjusted life-months (QALMs).

Results

The neoadjuvant chemoradiation arm consisted of 164 patients who completed preoperative therapy. Of these, 36 (22 %) did not proceed to surgery; 12 (7 %) underwent laparotomy but had unresectable disease; and 116 (71 %) underwent definitive resection. The surgery-first approach cost $46,830 and yielded survival of 8.7 QALMs; the neoadjuvant chemoradiation approach cost $36,583 and yielded survival of 18.8 QALMs. In the neoadjuvant arm, costs and survival times for patients not undergoing surgery, those with unresectable disease at laparotomy, and those completing surgery were $12,401 and 7.7 QALMs, $20,380 and 7.1 QALMs, and $45,673 and 23.4 QALMs, respectively.

Conclusions

Neoadjuvant chemoradiation for pancreatic cancer identifies patients with early metastases or poor performance status, who can be spared an ineffective or prohibitively morbid operation, and is associated with improved survival at significantly lower cost than a surgery-first approach. Neoadjuvant chemoradiation followed by surgery is a strategy that provides more cost-effective care than a surgery-first approach.

Copyright information

© Society of Surgical Oncology 2013

Authors and Affiliations

  • Daniel E. Abbott
    • 1
  • Ching-Wei David Tzeng
    • 2
  • Ryan P. Merkow
    • 3
    • 4
  • Scott B. Cantor
    • 5
  • George J. Chang
    • 2
  • Matthew Harold Katz
    • 2
  • David J. Bentrem
    • 4
    • 6
  • Karl Y. Bilimoria
    • 3
    • 4
  • Christopher H. Crane
    • 7
  • Gauri R. Varadhachary
    • 8
  • James L. Abbruzzese
    • 8
  • Robert A. Wolff
    • 8
  • Jeffrey E. Lee
    • 2
  • Douglas B. Evans
    • 9
  • Jason B. Fleming
    • 2
  1. 1.Department of SurgeryUniversity of Cincinnati School of MedicineCincinnatiUSA
  2. 2.Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Division of Research and Optimal Patient CareAmerican College of SurgeonsChicagoUSA
  4. 4.Department of SurgeryNorthwestern University/Feinberg School of MedicineChicagoUSA
  5. 5.Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonUSA
  6. 6.Department of SurgeryJesse Brown VA Medical CenterChicagoUSA
  7. 7.Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  8. 8.Department of Gastrointestinal Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  9. 9.Department of SurgeryMedical College of WisconsinMilwaukeeUSA