Queen Elizabeth Hospital, London, UK; Department of Surgery and Cancer, Imperial College London, UK.
St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK.
Clin Oncol (R Coll Radiol). 2018 Oct;30(10):625-633. doi: 10.1016/j.clon.2018.06.010. Epub 2018 Jul 7.
Emerging evidence suggests that contact X-ray brachytherapy (CXB) may increase the clinical complete response rate and durability when administered after standard chemoradiotherapy in patients with rectal cancer. The addition of CXB in partial responders is therefore probably cost-effective. The affordability of widening access to CXB in the UK, however, has not been evaluated.
Decision analytical modelling with Monte Carlo simulation was used to evaluate long-term costs for the management of patients with rectal cancers who were given a CXB boost when a clinical complete response was not initially achieved following chemoradiotherapy in order to facilitate a watch and wait approach. A third-party payer (National Health Service) perspective was adopted, probabilistic sensitivity analysis was carried out and a scenario analysis was performed to investigate the effect of the number of referral centres and number of patients treated with CXB.
We estimate that 818 (95% confidence interval 628-1021) patients per year are eligible for CXB as an adjunct to a watch and wait approach in England and Wales. As this management is less costly than surgical management for each individual patient, the more patients treated, the more affordable the technology. Even if as few as 125 patients are treated nationally in 15 centres, the cost of implementing this technology would be less than £4 million. If the average number of patients treated in each centre is 30, this technology would be cost saving within 5 years.
The cost of CXB is not prohibitive according to the National Institute for Health and Care Excellence threshold for implementation of new technology and may even be cost saving within 5 years compared with standard surgical management, depending on the uptake of the technology and the number of referral centres.
新出现的证据表明，在接受标准放化疗后，接触式 X 射线近距离放疗（CXB）可能会增加直肠癌患者的临床完全缓解率和缓解持续时间。因此，在部分缓解患者中添加 CXB 可能具有成本效益。然而，尚未评估在英国扩大 CXB 获得途径的负担能力。
使用蒙特卡罗模拟的决策分析模型来评估那些在接受放化疗后未获得临床完全缓解的直肠癌患者在接受 CXB 辅助治疗时的长期管理成本，以促进观察等待方法。采用第三方付款人（国家卫生服务）的观点进行概率敏感性分析，并进行情景分析以调查转诊中心数量和接受 CXB 治疗的患者数量对结果的影响。
我们估计，每年有 818 名（95%置信区间 628-1021 名）英格兰和威尔士的患者有资格接受 CXB 作为观察等待方法的辅助手段。由于这种管理方法对每个患者的成本低于手术管理，因此治疗的患者越多，技术的负担能力就越高。即使全国只有 15 个中心治疗 125 名患者，实施这项技术的成本也将低于 400 万英镑。如果每个中心治疗的平均患者人数为 30 人，则该技术将在 5 年内实现成本节约。
根据新英格兰临床优化研究所实施新技术的成本效益标准，CXB 的成本并非不可承受，并且与标准手术管理相比，在 5 年内甚至可能具有成本效益，具体取决于该技术的采用率和转诊中心的数量。
