Cancer In The Oropharynx: Can We Prioritize Treatment Modalities Based On Costs Of Primary Treatment, Anticipated Relapses And Grade Iii/Iv Complications

This paper studies whether, by taking costs into consideration, one could prioritize treatment modalities. With this in mind we compared full hospital costs when using different treatment modalities for oropharyngeal (OPh) cancers, the associated costs of the anticipated locoregional relapses (LRR) and/or severe treatment related RTOG grade III/IV complications (COM) necessitating hospital admission, inclusive. From 1991–2001 (censor date of survival and cost analyses September 1, 2003), 524 primary OPh cancers were treated in the Erasmus MC; 180 were excluded because of tumors being of non-squamous cell origin, second primaries, synchronous primary tumors, and/or treatment given with palliative intent. Patients with OPh cancer are treated in the Erasmus MC preferably by means of an organ function preservation protocol. That is, by external beam radiation therapy (EBRT) + brachytherapy (BT) boost, and neck dissection in case of N+ disease (BT-group: 157 patients). If BT is not feasible, resection with postoperative EBRT (S-group: 110 patients) or EBRT-alone (EBRT-group: 77 patients) is being pursued. Actuarial locoregional control (LRC), disease free survival (DFS) and overall survival (OS) at 5-yrs were calculated according to Kaplan Meier. Mean costs of the diagnostic phase and primary Tx, costs of follow-up (FU in months) and mean costs of (salvage of) locoregional relapse (LRR), distant metastasis (DM), or grade III/IV COM, were calculated. At 5-yrs LRC, DFS and OS for OPh cancers was 77%, 52%, and 56%, respectively. The clinical outcome per treatment group for LRC at 5-yrs was 85% (BT), 82% (S), and 55% (EBRT). For the DFS, 61%, 48%, and 43%, and for the OS 65%, 52%, and 40% was observed for the BT-group, S-group and EBRT-group, respectively. The mean costs per category and total mean costs are denoted per treatment group in the corresponding sections of the flow chart (see figure: number of patients between brackets). The clinical outcome illustrates excellent LRC rates at 5-yrs for BT (85%) as well as for S (82%). The 55% LRC rate at 5-yrs for EBRT might reflect the negative selection of patients undergoing this type of treatment, given the Erasmus MC protocol. The total mean costs of patients alive NED is least for the BT-group: that is $19197 (BT), $32148 (S), and $23705 (EBRT). The mean costs of primary Tx in case of BT ($16044) and EBRT-only ($13113) were less as opposed to S ($24687). Moreover, the mean costs of S as a salvage modality for the LRR of the BT-group and EBRT-group, were high ($22706 and $22187, respectively). Also, the mean costs of clinical management of Grade III/IV COM were substantially higher in the S-group ($9481 [BT] vs. $21198 [S] vs. $11457 [EBRT]). Main underlying cause for high costs with S as opposed to RT is the number of associated clinical admission days. That is, in case of a LRR 14(BT) vs. 21(S) vs. 17 (EBRT) days, and for COM 15 (BT) vs. 31 (S) vs. 14 (EBRT). Other discriminating factors, like costs, could be of additional value in prioritizing treatment modalities.