title: Effectiveness and cost-effectiveness of peri-operative versus post-operative chemotherapy for resectable colorectal liver metastases.
abstract: BACKGROUND
  The role of neo-adjuvant chemotherapy prior to hepatectomy in patients with resectable colorectal liver metastases is currently a matter of debate. The aim of the present study was to analyse life-expectancy, quality adjusted life-expectancy and cost-effectiveness of the two chemotherapeutic strategies.
  
  
  METHODS
  A Markov decision model was developed, on the basis of parameters derived from an extensive literature search of the last ten years, to compare outcomes of peri-operative versus post-operative chemotherapy.
  
  
  RESULTS
  Life-expectancy observed for peri-operative chemotherapy was 54.56months and 52.62months with post-operative chemotherapy only; the quality-adjusted life-expectancy with peri-operative chemotherapy was 39.33 quality-adjusted life-months (QALMs) and 37.84 QALMs with post-operative chemotherapy. Peri-operative chemotherapy results in an increase in total costs of 1180€ over ten years and in an incremental cost-effectiveness ratio (ICER) of 791.9€/QALM. The model was more sensitive to the expected 3-year recurrence-free survival (RFS) and cost of hepatic resection: with respect to an expected 3-year RFS⩽25% the peri-operative approach was more cost-effective than post-operative strategy but differences in average cost-effectiveness were small. The relationship between ICER and cost of hepatic resection was inverse because the higher the cost of hepatic resection, the higher the cost saving due to patients becoming unresectable during neo-adjuvant therapy.
  
  
  CONCLUSIONS
  In the treatment of resectable colorectal liver metastases, the addition of neo-adjuvant chemotherapy could be cost-effective because it makes it possible to avoid hepatic resection in patients who do not respond to the neo-adjuvant approach; however, the life-expectancy of the two strategies is very similar.
authors.affiliation: Liver and Multiorgan Transplant Unit, University of Bologna, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Ercolani
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cucchetti
authors.forename: Matteo
authors.initials: M
authors.lastname: Cescon
authors.forename: Eugenia
authors.initials: E
authors.lastname: Peri
authors.forename: Giovanni
authors.initials: G
authors.lastname: Brandi
authors.forename: Massimo
authors.initials: M
authors.lastname: Del Gaudio
authors.forename: Matteo
authors.initials: M
authors.lastname: Ravaioli
authors.forename: Matteo
authors.initials: M
authors.lastname: Zanello
authors.forename: Antonio Daniele
authors.initials: AD
authors.lastname: Pinna
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant / Q000191:economics; D015179:Colorectal Neoplasms / Q000191:economics / Q000401:mortality / Q000473:pathology*; D003362:Cost-Benefit Analysis; D018572:Disease-Free Survival; D017048:Health Care Costs; D006498:Hepatectomy / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D006801:Humans; D008017:Life Expectancy; D008113:Liver Neoplasms / Q000188:drug therapy* / Q000191:economics* / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D008390:Markov Chains; D018803:Models, Economic; D020360:Neoadjuvant Therapy / Q000191:economics; D019057:Quality-Adjusted Life Years; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome