Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.
Ann Surg Oncol. 2013 Dec;20 Suppl 3:S500-8. doi: 10.1245/s10434-013-2882-0. Epub 2013 Feb 10.
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.
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).
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.
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.
在治疗胰腺癌时，化疗、放疗和手术的最佳顺序尚未明确。因此，应该考虑成本效益。本研究旨在比较手术优先与新辅助放化疗后手术治疗可切除胰头癌的成本效益。
构建决策分析模型比较两种方法。手术优先组的数据来自国家癌症数据库、国家手术质量改进计划和文献，新辅助组的数据来自我们前瞻性维护的机构胰腺癌数据库。成本按医疗保险支付额（2011 年美元）估算。生存以质量调整生命月（QALMs）报告。
新辅助放化疗组包括 164 例完成术前治疗的患者。其中 36 例（22%）未行手术；12 例（7%）行剖腹术但疾病不可切除；116 例（71%）行确定性切除术。手术优先组的费用为 46830 美元，生存获益为 8.7 QALMs；新辅助放化疗组的费用为 36583 美元，生存获益为 18.8 QALMs。在新辅助组中，未行手术、剖腹术时疾病不可切除以及完成手术的患者的费用和生存时间分别为 12401 美元和 7.7 QALMs、20380 美元和 7.1 QALMs、45673 美元和 23.4 QALMs。
新辅助放化疗可识别出有早期转移或较差体能状态的患者，使他们免于接受无效或可能导致严重病残的手术，并显著降低成本，提高生存获益。新辅助放化疗后手术是一种比手术优先策略更具成本效益的治疗方法。
