Annals of Surgical Oncology

, Volume 20, Issue 7, pp 2197–2203 | Cite as

Frequency and Intensity of Postoperative Surveillance After Curative Treatment of Pancreatic Cancer: A Cost-Effectiveness Analysis

  • Ching-Wei D. Tzeng
  • Daniel E. Abbott
  • Scott B. Cantor
  • Jason B. Fleming
  • Jeffrey E. Lee
  • Peter W. T. Pisters
  • Gauri R. Varadhachary
  • James L. Abbruzzese
  • Robert A. Wolff
  • Syed A. Ahmad
  • Matthew H. G. Katz
Pancreatic Tumors



Few data exist to guide oncologic surveillance following curative treatment of pancreatic cancer. We sought to identify a rational, cost-effective postoperative surveillance strategy.


We constructed a Markov model to compare the cost-effectiveness of 5 postoperative surveillance strategies. No scheduled surveillance served as the baseline strategy. Clinical evaluation and carbohydrate antigen (CA) 19-9 testing without/with routine computed tomography and chest X-ray at either 6- or 3-month intervals served as the 4 comparison strategies of increasing intensity. We populated the model with symptom, recurrence, treatment, and survival data from patients who had received intensive surveillance after multimodality treatment at our institution between 1998 and 2008. Costs were based on Medicare payments (2011 US dollars).


The baseline strategy of no scheduled surveillance was associated with a postoperative overall survival (OS) of 24.6 months and a cost of $3837/patient. Clinical evaluation and CA 19-9 assay every 6 months until recurrence was associated with a 32.8-month OS and a cost of $7496/patient, with an incremental cost-effectiveness ratio (ICER) of $5364/life-year (LY). Additional routine imaging every 6 months incrementally increased total cost by $3465 without increasing OS. ICERs associated with clinic visits every 3 months without/with routine imaging were $127,680 and $294,696/LY, respectively. Sensitivity analyses changed the strategies’ absolute costs but not the relative ranks of their ICERs.


Increasing the frequency and intensity of postoperative surveillance of patients after curative therapy for pancreatic cancer beyond clinical evaluation and CA 19-9 testing every 6 months increases cost but confers no clinically significant survival benefit.


Overall Survival National Comprehensive Cancer Network National Comprehensive Cancer Network Carbohydrate Antigen National Comprehensive Cancer Network Guideline 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Sarah Bronson and Kathryn Carnes for their scientific editing of this manuscript. Supported by the Khalifa Bin Zayed Al Nahyan Foundation and the Various Donor Pancreatic Research Fund at The University of Texas MD Anderson Cancer Center.



Supplementary material

10434_2013_2889_MOESM1_ESM.doc (34 kb)
Supplementary material 1 (DOC 34 kb)


  1. 1.
    Breslin TM, Hess KR, Harbison DB, Jean ME, Cleary KR, Dackiw AP, et al. Neoadjuvant chemoradiotherapy for adenocarcinoma of the pancreas: treatment variables and survival duration. Ann Surg Oncol. 2001;8:123–32.PubMedCrossRefGoogle Scholar
  2. 2.
    Thomas RM, Truty MJ, Nogueras-Gonzalez GM, Fleming JB, Vauthey JN, Pisters PW, et al. Selective reoperation for locally recurrent or metastatic pancreatic ductal adenocarcinoma following primary pancreatic resection. J Gastrointest Surg. 2012;16:1696–704.PubMedCrossRefGoogle Scholar
  3. 3.
    Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, et al. Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Ann Surg. 2007;246:52–60.PubMedCrossRefGoogle Scholar
  4. 4.
    Katz MH, Wang H, Fleming JB, Sun CC, Hwang RF, Wolff RA, et al. Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol. 2009;16:836–47.PubMedCrossRefGoogle Scholar
  5. 5.
    Oettle H, Post S, Neuhaus P, Gellert K, Langrehr J, Ridwelski K, et al. Adjuvant chemotherapy with gemcitabine versus observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007;297:267–77.PubMedCrossRefGoogle Scholar
  6. 6.
    Smeenk HG, van Eijck CH, Hop WC, Erdmann J, Tran KC, Debois M, et al. Long-term survival and metastatic pattern of pancreatic and periampullary cancer after adjuvant chemoradiation or observation: long-term results of EORTC trial 40891. Ann Surg. 2007;246:734–40.PubMedCrossRefGoogle Scholar
  7. 7.
    Tjandra JJ, Chan MK. Follow-up after curative resection of colorectal cancer: a meta-analysis. Dis Colon Rectum. 2007;50:1783–99.PubMedCrossRefGoogle Scholar
  8. 8.
    Rodriguez-Moranta F, Salo J, Arcusa A, Boadas J, Piñol V, Bessa X, et al. Postoperative surveillance in patients with colorectal cancer who have undergone curative resection: a prospective, multicenter, randomized, controlled trial. J Clin Oncol. 2006;24:386–93.PubMedCrossRefGoogle Scholar
  9. 9.
    Rojas MP, Telaro E, Russo A, Moschetti I, Coe L, Fossati R, et al. Follow-up strategies for women treated for early breast cancer. Cochrane Database Syst Rev. 2005;(1):CD001768.Google Scholar
  10. 10.
    Salerni G, Lovatto L, Carrera C, Puig S, Malvehy J. Melanomas detected in a follow-up program compared with melanomas referred to a melanoma unit. Arch Dermatol. 2011;147:549–55.PubMedCrossRefGoogle Scholar
  11. 11.
    Tzeng CW, Fleming JB, Lee JE, Wang X, Pisters PW, Vauthey JN, et al. Yield of clinical and radiographic surveillance in patients with resected pancreatic adenocarcinoma following multimodal therapy. HPB (Oxford). 2012;14:365–72.CrossRefGoogle Scholar
  12. 12.
    Sheffield KM, Crowell KT, Lin YL, Djukom C, Goodwin JS, Riall TS. Surveillance of pancreatic cancer patients after surgical resection. Ann Surg Oncol. 2012;19:1670–7.PubMedCrossRefGoogle Scholar
  13. 13.
    NCCN. Pancreatic adenocarcinoma Version 2.2012. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Fort Washington: National Comprehensive Cancer Network; 2012.Google Scholar
  14. 14.
    Hwang RF, Wang H, Lara A, Gomez H, Chang T, Sieffert N, et al. Development of an integrated biospecimen bank and multidisciplinary clinical database for pancreatic cancer. Ann Surg Oncol. 2008;15:1356–66.PubMedCrossRefGoogle Scholar
  15. 15.
    Evans DB, Varadhachary GR, Crane CH, Sun CC, Lee JE, Pisters PW, et al. Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol. 2008;26:3496–502.PubMedCrossRefGoogle Scholar
  16. 16.
    Katz MH, Pisters PW, Evans DB, Sun CC, Lee JE, Fleming JB, et al. Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am Coll Surg. 2008;206:833–46; discussion 846–848.PubMedCrossRefGoogle Scholar
  17. 17.
    Varadhachary GR, Wolff RA, Crane CH, Sun CC, Lee JE, Pisters PW, et al. Preoperative gemcitabine and cisplatin followed by gemcitabine-based chemoradiation for resectable adenocarcinoma of the pancreatic head. J Clin Oncol. 2008;26:3487–95.PubMedCrossRefGoogle Scholar
  18. 18.
    Yen TW, Abdalla EK, Pisters PW, Evans DB. Pancreaticoduodenectomy. In: Von Hoff DD, Evans DB, Hruban RH, eds. Pancreatic Cancer. Sudbury: Jones and Bartlett; 2005: p. 265–86.Google Scholar
  19. 19.
    Beck JR, Kassirer JP, Pauker SG. A convenient approximation of life expectancy (the “DEALE”). I. Validation of the method. Am J Med. 1982;73:883–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Beck JR, Pauker SG, Gottlieb JE, Klein K, Kassirer JP. A convenient approximation of life expectancy (the “DEALE”). II. Use in medical decision-making. Am J Med. 1982;73:889–97.PubMedCrossRefGoogle Scholar
  21. 21.
    Ljungman D, Lundholm K, Hyltander A. Cost-utility estimation of surgical treatment of pancreatic carcinoma aimed at cure. World J Surg. 2011;35:662–70.PubMedCrossRefGoogle Scholar
  22. 22.
    Murphy JD, Chang DT, Abelson J, Daly ME, Yeung HN, Nelson LM, et al. Cost-effectiveness of modern radiotherapy techniques in locally advanced pancreatic cancer. Cancer. 2012;118:1119–29.PubMedCrossRefGoogle Scholar
  23. 23.
    Cantor SB. Cost-effectiveness analysis, extended dominance, and ethics: a quantitative assessment. Med Decis Mak. 1994;14:259–65.CrossRefGoogle Scholar
  24. 24.
    Braithwaite RS, Meltzer DO, King JT, Jr., Leslie D, Roberts MS. What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule? Med Care. 2008;46:349–56.PubMedCrossRefGoogle Scholar
  25. 25.
    Conroy T, Desseigne F, Ychou M, Bouché O, Guimbaud R, Bécouarn Y, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med. 2011;364:1817–25.PubMedCrossRefGoogle Scholar
  26. 26.
    Arora NK, Reeve BB, Hays RD, Clauser SB, Oakley-Girvan I. Assessment of quality of cancer-related follow-up care from the cancer survivor’s perspective. J Clin Oncol. 2011;29:1280–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Katz MH, Hu CY, Fleming JB, Pisters PW, Lee JE, Chang GJ. Clinical calculator of conditional survival estimates for resected and unresected survivors of pancreatic cancer. Arch Surg. 2012;147:513–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Thompson CA, Charlson ME, Schenkein E, Wells MT, Furman RR, Elstrom R, et al. Surveillance CT scans are a source of anxiety and fear of recurrence in long-term lymphoma survivors. Ann Oncol. 2010;21:2262–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Petzel MQ, Parker NH, Valentine AD, Simard S, Nogueras-Gonzalez GM, Lee JE, et al. Fear of cancer recurrence after curative pancreatectomy: a cross-sectional study in survivors of pancreatic and periampullary tumors. Ann Surg Oncol. 2012;19:4078–84.PubMedCrossRefGoogle Scholar
  30. 30.
    Asiyanbola B, Gleisner A, Herman JM, Choti MA, Wolfgang CL, Swartz M, et al. Determining pattern of recurrence following pancreaticoduodenectomy and adjuvant 5-flurouracil-based chemoradiation therapy: effect of number of metastatic lymph nodes and lymph node ratio. J Gastrointest Surg. 2009;13:752–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Meyers MO, Meszoely IM, Hoffman JP, Watson JC, Ross E, Eisenberg BL. Is reporting of recurrence data important in pancreatic cancer? Ann Surg Oncol. 2004;11:304–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Ballehaninna UK, Chamberlain RS. The clinical utility of serum CA 19-9 in the diagnosis, prognosis and management of pancreatic adenocarcinoma: an evidence based appraisal. J Gastrointest Oncol. 2012;3:105–19.PubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2013

Authors and Affiliations

  • Ching-Wei D. Tzeng
    • 1
  • Daniel E. Abbott
    • 2
  • Scott B. Cantor
    • 3
  • Jason B. Fleming
    • 1
  • Jeffrey E. Lee
    • 1
  • Peter W. T. Pisters
    • 1
  • Gauri R. Varadhachary
    • 4
  • James L. Abbruzzese
    • 4
  • Robert A. Wolff
    • 4
  • Syed A. Ahmad
    • 2
  • Matthew H. G. Katz
    • 1
  1. 1.Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Division of Surgical OncologyUniversity of CincinnatiCincinnatiUSA
  3. 3.Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.Department of Gastrointestinal Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA

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