Spolverato Gaya, Vitale Alessandro, Ejaz Aslam, Cosgrove David, Cowzer Darren, Cillo Umberto, Pawlik Timothy M
Department of Surgery, Division of Surgical Oncology, The Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD, 21287, USA.
J Gastrointest Surg. 2015 Sep;19(9):1668-75. doi: 10.1007/s11605-015-2873-5. Epub 2015 Jun 16.
We sought to estimate the cost-effectiveness of hepatic resection (HR) (strategy A) relative to surveillance plus 6 months of additional systemic chemotherapy (sCT) (strategy B) for patients with colorectal disappearing liver metastases (DLM).
A Markov model was developed using data from a systematic literature review. Three base cases were evaluated: (1) a 60-year-old patient with three lesions in the right hemi-liver who underwent 6 months of sCT, had normalized carcinoembryonic antigen (CEA), and was diagnosed with DLM through a computed tomography (CT) scan; (2) a 60-year-old patient with three lesions in the right hemi-liver who underwent 6 months of sCT, had normalized CEA, and was diagnosed with DLM through a magnetic resonance imaging (MRI) scan; and (3) a 60-year-old patient with three lesions in the right hemi-liver who underwent 6 months of sCT plus hepatic artery infusion (HAI), had normalized CEA, and was diagnosed with DLM through a MRI scan. The outcomes evaluated were quality-adjusted life months (QALMs), incremental cost-effectiveness ratio (ICER), and net health benefit (NHB).
The NHB of strategy A versus strategy B was positive in base case 1 (7.7 QALMs, ICER $34.449/quality-adjusted life year (QALY)) and base case 2 (1.6 QALMs, ICER $43,948/QALY). In contrast it was negative (-0.2 QALMs, ICER $72,474/QALY) for base case 3. Monte Carlo simulation showed that strategy B is acceptable only in old patients (>60 years) with normalized CEA and MRI-based diagnosis. In younger patients, strategy B may reach cost-effectiveness only after sCT plus HAI.
Surveillance of DLM after sCT was more beneficial and cost-effective among patients >60 years with multiple factors predictive of true complete pathological response, such as normalization of CEA, HAI therapy, BMI ≤30 kg/m(2), and diagnosis of DLM made through MRI.
我们试图评估肝切除（HR）（策略A）相对于监测加6个月额外全身化疗（sCT）（策略B）对结直肠癌肝转移消失（DLM）患者的成本效益。
使用系统文献综述的数据建立了一个马尔可夫模型。评估了三个基础病例：（1）一名60岁患者，右半肝有三个病灶，接受了6个月的sCT，癌胚抗原（CEA）恢复正常，并通过计算机断层扫描（CT）诊断为DLM；（2）一名60岁患者，右半肝有三个病灶，接受了6个月的sCT，CEA恢复正常，并通过磁共振成像（MRI）诊断为DLM；（3）一名60岁患者，右半肝有三个病灶，接受了6个月的sCT加肝动脉灌注（HAI），CEA恢复正常，并通过MRI诊断为DLM。评估的结果包括质量调整生命月（QALMs）、增量成本效益比（ICER）和净健康效益（NHB）。
在基础病例1（7.7个QALMs，ICER为34449美元/质量调整生命年（QALY））和基础病例2（1.6个QALMs，ICER为43948美元/QALY）中，策略A相对于策略B的NHB为正。相比之下，基础病例3的NHB为负（-0.2个QALMs，ICER为72474美元/QALY）。蒙特卡罗模拟表明，策略B仅在CEA恢复正常且基于MRI诊断的老年患者（>60岁）中可接受。在年轻患者中，策略B可能仅在sCT加HAI后才具有成本效益。
在年龄>60岁、具有多种预测真正完全病理缓解的因素（如CEA恢复正常、HAI治疗、BMI≤30kg/m²以及通过MRI诊断DLM）的患者中，sCT后对DLM进行监测更有益且具有成本效益。
