Abstract
Background
Nonoperative management (NOM) of rectal cancer after radiochemotherapy (RtChx) in patients with a clinical complete response is an emerging strategy with the goal to improve quality of life without compromising cure rates. However close monitoring with both magnetic resonance imaging (MRI) and rectoscopy is required for the early detection of possible local regrowths. We therefore performed a cost analysis comparing the costs of immediate surgery with the costs for MRI and rectoscopy during surveillance as in the upcoming CAO/ARO/AIO-16 trial.
Methods
MRIs and rectoscopies of patients with a clinical complete response after RtChx over the course of 5 years were simulated and compared with immediate surgery after RtChx. Transition probabilities between health stages (no evidence of disease, local regrowth and salvage surgery, distant failure) were derived from the literature. Costs for ambulatory imaging and endoscopic studies were calculated according to the “Gebührenordnung für Ärzte” (GOÄ), costs for surgery based on the diagnosis-related groups system. Three different scenarios with higher costs for salvage surgery or higher regrowth rates were simulated.
Results
A patient without disease recurrence will generate costs for MRI and rectoscopy of 6344 € over 5 years compared with costs of 14,511 € for immediate radical surgery. When 25% local regrowths with subsequent salvage surgery were included in the model, the average costs per patient are 8299 €. In our simulations a NOM strategy was cost-saving compared with immediate surgery in all three scenarios.
Conclusion
A NOM strategy with an intensive surveillance using MRI and rectoscopy will produce costs that are expected to remain below those of immediate surgery.
Zusammenfassung
Hintergrund
Das nichtoperative Management (NOM) des Rektumkarzinoms im Fall einer klinischen Komplettremission nach Radiochemotherapie ist eine intensiv diskutierte Option mit dem Ziel der Verbesserung der Lebensqualität, ohne die Heilungschancen zu beeinträchtigen. Allerdings wird zur frühzeitigen Detektion eines lokalen Nachwachsens („local regrowth“, LR) des Tumors eine engmaschige Überwachung mittels Rektoskopie und Magnetresonanztomographie (MRT) empfohlen. Ziel der gegenwärtigen Arbeit ist es daher, die Kosten dieser Verlaufskontrollen, wie sie in der bevorstehenden CAO/ARO/AIO-16 Studie zum Einsatz kommen werden, denen der operativen Strategie gegenüberzustellen.
Methoden
Die Kosten für die MRT und Rektoskopie bei Patienten mit einer klinischen Komplettremission nach Radiochemotherapie (RtChx) wurden über 5 Jahre hinweg simuliert und mit denen einer Operation nach RtChx verglichen. Die Übergangswahrscheinlichkeiten zwischen Erkrankungsstadien (vollständige Remission, LR mit Salvage-Operation, distante Metastasierung) wurden aus der Literatur übernommen. Die Kosten für ambulante Bildgebung und Rektoskopien wurden nach der Gebührenordnung für Ärzte (GOÄ) berechnet, die Kosten für eine Operation basieren auf dem Diagnosis-Related-Groups-System (DRG). Drei verschiedene Szenarien mit höheren Kosten für die Salvage-OP oder höheren Wahrscheinlichkeiten für das Wiederauftreten der Erkrankung wurden simuliert.
Ergebnisse
Für einen Patienten, der kein Rezidiv entwickelt, entstehen über 5 Jahre Kosten für MRT und Rektoskopie von 6344 € im Vergleich zu Kosten von 14.511 € für eine Operation. Wird eine LR-Rate von 25 % mit anschließender Salvage-Op. berücksichtigt, betragen die durchschnittlichen Kosten pro Patient 8299 €. In der gegenwärtigen Studie war eine NOM-Strategie in allen Szenarien kostensparend gegenüber dem operativen Ansatz.
Schlussfolgerung
Eine NOM-Strategie mit engmaschiger Überwachung mittels MRT und Rektoskopie verursacht Kosten, die höchstwahrscheinlich unter denen des operativen Vorgehens liegen.
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Acknowledgements
The authors would like to thank Jagoda Kibele, Christiane Littau and Volker Naujoks for providing DRG and OPS codes.
Funding
Cihan Gani is supported by the Clinician Scientist Program of the Medical Faculty, Eberhard Karls Universität Tübingen [Funding number: 363–0-0].
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C. Gani, U. Grosse, S. Clasen, A. Kirschniak, M. Goetz, C. Rödel and D. Zips declare that they have no competing interests.
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Gani, C., Grosse, U., Clasen, S. et al. Cost analysis of a wait-and-see strategy after radiochemotherapy in distal rectal cancer. Strahlenther Onkol 194, 985–990 (2018). https://doi.org/10.1007/s00066-018-1327-x
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DOI: https://doi.org/10.1007/s00066-018-1327-x