Mitzman Brian, Varghese Thomas K, Akerley Wallace L, Nelson Richard E
Department of Surgery, University of Utah, Salt Lake City, UT, USA.
Huntsman Cancer Institute, Salt Lake City, UT, USA.
J Thorac Dis. 2024 Feb 29;16(2):1063-1073. doi: 10.21037/jtd-23-1538. Epub 2024 Feb 26.
Identification of unsuspected nodal metastasis may occur at the time of operation for a stage I non-small cell lung cancer. Guidelines for this scenario are unclear. Our goal was to assess the cost-effectiveness of aborting the operation in an attempt to first provide neoadjuvant systemic therapy compared with upfront resection.
A computer simulation Markov model with a lifetime horizon was constructed to compare the costs and clinical outcomes, as measured by quality-adjusted life-years (QALYs), of upfront resection at the time of identification of unsuspected N2 mediastinal disease aborting initial resection and continuing with neoadjuvant therapy prior to resection. Input parameters for the model were derived from published literature with costs measured from the healthcare perspective. The incremental cost-effectiveness ratio (ICER) was evaluated with a willingness-to-pay (WTP) threshold of $150,000/QALY. Both deterministic (one-, two-, and three-way) and probabilistic sensitivity analysis (PSA) were performed to assess the impact of variation in input parameter values on model results.
Aborting initial resection in favor of neoadjuvant therapy resulted in both higher costs ($40,415 $29,873) and more QALYs (3.95 2.84) relative to upfront resection, yielding an ICER of $9,526/QALY. While variation in overall survival had a significant impact on the ICER, perioperative variables did not. As the annual mortality of best-case therapy in the abort group increased from a base-case estimate of 11% to 15%, the ICER exceeded the WTP threshold of $150,000/QALY. Subsequent one- and two-way sensitivity analyses did not find substantially alter the overall results. PSA resulted in aborting resection to be cost-effective in 99.7% of samples, with 13% of samples dominating upfront resection.
Treatment of stage IIIa lung cancer requires the input of a multidisciplinary team who must consider cost, quality of life, and overall survival. As new treatments are developed, further analyses should be performed to determine optimal therapy.
在对I期非小细胞肺癌进行手术时，可能会发现未被怀疑的淋巴结转移。针对这种情况的指南尚不明确。我们的目标是评估与直接切除相比，先尝试进行新辅助全身治疗而中止手术的成本效益。
构建了一个具有终身视野的计算机模拟马尔可夫模型，以比较在发现未被怀疑的N2纵隔疾病时直接切除与中止初始切除并在切除前继续进行新辅助治疗的成本和临床结局（以质量调整生命年（QALY）衡量）。模型的输入参数来自已发表的文献，成本从医疗保健角度衡量。采用支付意愿（WTP）阈值为150,000美元/QALY来评估增量成本效益比（ICER）。进行了确定性（单因素、双因素和三因素）和概率敏感性分析（PSA），以评估输入参数值的变化对模型结果的影响。
相对于直接切除，中止初始切除而采用新辅助治疗导致成本更高（40,415美元对29,873美元），QALY更多（3.95对2.84），ICER为9,526美元/QALY。虽然总生存的变化对ICER有显著影响，但围手术期变量没有。当中止组最佳治疗的年度死亡率从基础病例估计的11%增加到15%时，ICER超过了150,000美元/QALY的WTP阈值。随后的单因素和双因素敏感性分析并未发现总体结果有实质性改变。PSA结果显示，在99.7%的样本中，中止切除具有成本效益，13%的样本优于直接切除。
IIIa期肺癌的治疗需要多学科团队的参与，他们必须考虑成本、生活质量和总生存。随着新治疗方法的开发，应进行进一步分析以确定最佳治疗方案。
