Martinez J M, Anene A, Bentley T G K, Cangelosi M J, Meckley L M, Ortendahl J D, Montero A J
University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA.
Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA.
J Gastrointest Cancer. 2017 Mar;48(1):58-65. doi: 10.1007/s12029-016-9907-4.
ASGE and ESGE guidelines recommend endoscopic metal stent placement for pancreatic carcinoma patients with biliary obstruction, and whose estimated life expectancy is greater than 6 months. Because median overall survival (OS) of metastatic pancreatic adenocarcinoma until recently has been less than 6 months, plastic biliary stents were preferentially placed rather than metal due to the greater upfront cost of the latter. Recent advances in the treatment of metastatic pancreatic cancer have extended median OS beyond the 6-month range. Given this improvement in OS, we performed a cost-effectiveness analysis of initial metal biliary versus plastic stent placement in metastatic pancreatic cancer patients with biliary obstruction.
A Markov model was developed to predict lifetime costs, quality-adjusted life years (QALYs), and cost effectiveness of metal compared with plastic stents. Adult patients entered the model with locally advanced cancer and underwent endoscopic retrograde cholangiopancreatography (ERCP) with placement of metal or plastic stents. A targeted literature search was conducted to identify published sources, which were used to estimate clinical, cost, utility, and event rate inputs to the model. Results were estimated from the third-party payer perspective in 2012 US dollars per QALY. One-way and probabilistic sensitivity analyses were conducted to assess the impact on model outcomes resulting from uncertainty among inputs.
Our analysis found that initial placement of metal stents was more cost effective than plastic biliary stents with lower overall costs due to lower restenting rates while at the same time associated with a better quality of life. Based on model projections, placement of metal stents could save approximately $1450 per patient over a lifetime, while simultaneously improving quality of life. These findings were robust in sensitivity analyses.
Placement of metal biliary stents at initial onset of obstructive jaundice in adult patients with metastatic pancreatic carcinoma with an expected OS greater than 6 months was found to be a more cost-effective strategy than plastic stents. These results reinforce guidelines' suggestions for metal stent placement.
美国胃肠内镜学会（ASGE）和欧洲胃肠内镜学会（ESGE）的指南推荐，对于预期生存期大于6个月的胆管梗阻胰腺癌患者，应行内镜金属支架置入术。由于直到最近转移性胰腺腺癌的中位总生存期（OS）仍不足6个月，且金属支架前期成本更高，因此优先置入塑料胆管支架。转移性胰腺癌治疗的最新进展已将中位OS延长至6个月以上。鉴于OS的这种改善，我们对转移性胆管梗阻胰腺癌患者初始置入金属胆管支架与塑料支架进行了成本效益分析。
建立马尔可夫模型，以预测金属支架与塑料支架的终身成本、质量调整生命年（QALY）和成本效益。成年患者以局部晚期癌症进入模型，并接受内镜逆行胰胆管造影（ERCP）及金属或塑料支架置入。进行了有针对性的文献检索，以确定已发表的资料来源，用于估计模型的临床、成本、效用和事件发生率输入。结果是从第三方支付方的角度以2012年美元/ QALY为单位进行估计的。进行了单因素和概率敏感性分析，以评估输入不确定性对模型结果的影响。
我们的分析发现，初始置入金属支架比塑料胆管支架更具成本效益，总体成本更低，因为再置入率更低，同时生活质量更高。根据模型预测，置入金属支架每位患者一生可节省约1450美元，同时提高生活质量。这些发现在敏感性分析中很稳健。
对于预期OS大于6个月的转移性胰腺癌成年患者，在梗阻性黄疸初发时置入金属胆管支架被发现是比塑料支架更具成本效益的策略。这些结果强化了指南中关于金属支架置入的建议。
