Department of Surgery, Tufts Medical Center, Boston, MA.
Tufts University School of Medicine, Boston, MA.
J Am Coll Surg. 2021 Jun;232(6):837-845. doi: 10.1016/j.jamcollsurg.2021.02.013. Epub 2021 Mar 5.
Lymph node transfer (LNT) and lymphovenous bypass (LVB) have been described as 2 major surgical options for patients with breast cancer-related lymphedema (BCRL) who have failed conservative therapy. The objective of our study was to perform a cost-effectiveness analysis comparing LNT and LVB for the treatment of BCRL.
Rates of infection, lymph leak, and failure of LNT and LVB were obtained from a previously published meta-analysis. Failure of surgery was defined as the inability to cease compression therapy postoperatively. Procedural costs were calculated from Medicare reimbursement rates. Cost of conservative management of postoperative surgical site infection, lymph leak, and continued decongestive physiotherapy after failed surgery were obtained from literature review. Average utility scores for each health state were calculated using a visual analog scale survey, then converted to quality-adjusted life years (QALYs). A decision tree was constructed, and incremental cost-effectiveness ratio was assessed at $50,000/QALY. Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness of our findings.
LNT was less costly ($22,492 vs $31,927) and more effective (31.82 QALY vs 29.24 QALY) than LVB. One-way (deterministic) sensitivity analysis demonstrated that LNT became cost-ineffective when its failure rate was more than 43.8%. LVB became more cost-effective than LNT when its failure rate was less than 21.4%. Probabilistic sensitivity analysis using Monte-Carlo simulation indicated that even with uncertainty present in the variables analyzed, the majority of simulations (97%) favored LNT as the more cost-effective strategy.
LNT is a dominant, cost-effective strategy compared to LVB for the treatment of BCRL.
淋巴结转移（LNT）和淋巴静脉旁路（LVB）已被描述为乳腺癌相关淋巴水肿（BCRL）患者在保守治疗失败后的两种主要手术选择。我们的研究目的是对 LNT 和 LVB 治疗 BCRL 的成本效益进行分析比较。
LNT 和 LVB 的感染、淋巴漏和手术失败率来自先前发表的荟萃分析。手术失败定义为术后无法停止压缩治疗。手术程序成本根据医疗保险报销率计算。从文献回顾中获得术后手术部位感染、淋巴漏和失败手术后持续的消肿物理治疗的保守管理成本。使用视觉模拟量表调查计算每个健康状态的平均效用得分，然后转换为质量调整生命年（QALY）。构建决策树，并在 50,000 美元/QALY 的增量成本效益比进行评估。进行确定性和概率敏感性分析以评估我们研究结果的稳健性。
LNT 的成本较低（22,492 美元对 31,927 美元），效果更好（31.82 QALY 对 29.24 QALY）。单因素（确定性）敏感性分析表明，当 LNT 的失败率超过 43.8%时，LNT 变得不经济。当 LVB 的失败率小于 21.4%时，LVB 变得比 LNT 更具成本效益。使用蒙特卡罗模拟的概率敏感性分析表明，即使在分析变量中存在不确定性，大多数模拟（97%）仍倾向于 LNT 作为更具成本效益的策略。
与 LVB 相比，LNT 是治疗 BCRL 的一种主导、具有成本效益的策略。
