title: The combined use of surgery and radiotherapy to treat patients with epidural cord compression due to metastatic disease: a cost-utility analysis.
abstract: Neoplastic metastatic epidural spinal cord compression is a common complication of cancer that causes pain and progressive neurologic impairment. The previous standard treatment for this condition involved corticosteroids and radiotherapy (RT). Direct decompressive surgery with postoperative radiotherapy (S + RT) is now increasingly being chosen by clinicians to significantly improve patients' ability to walk and reduce their need for opioid analgesics and corticosteroids. A cost-utility analysis was conducted to compare S + RT with RT alone based on the landmark randomized clinical trial by Patchell et al. (2005). It was performed from the perspective of the Ontario Ministry of Health and Long-Term Care. Ontario-based costs were adjusted to 2010 US dollars. S + RT is more costly but also more effective than corticosteroids and RT alone, with an incremental cost-effectiveness ratio of US$250 307 per quality-adjusted life year (QALY) gained. First order probabilistic sensitivity analysis revealed that the probability of S + RT being cost-effective is 18.11%. The cost-effectiveness acceptability curve showed that there is a 91.11% probability of S + RT being cost-effective over RT alone at a willingness-to-pay of US$1 683 000 per QALY. In practice, the results of our study indicate that, by adopting the S + RT strategy, there would still be a chance of 18.11% of not paying extra at a willingness-to-pay of US$50 000 per QALY. Those results are sensitive to the costs of hospice palliative care. Our results suggest that adopting a standard S + RT approach for patients with MSCC is likely to increase health care costs but would result in improved outcomes.
authors.affiliation: Division of Genetics and Development, Toronto Western Research Institute, Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada M5T 2S8. jcfurlan@gmail.com
authors.forename: Julio C
authors.initials: JC
authors.lastname: Furlan
authors.forename: Kelvin K-W
authors.initials: KK
authors.lastname: Chan
authors.forename: Guillermo A
authors.initials: GA
authors.lastname: Sandoval
authors.forename: Kenneth C K
authors.initials: KC
authors.lastname: Lam
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Klinger
authors.forename: Roy A
authors.initials: RA
authors.lastname: Patchell
authors.forename: Audrey
authors.initials: A
authors.lastname: Laporte
authors.forename: Michael G
authors.initials: MG
authors.lastname: Fehlings
mesh_terms: D003131:Combined Modality Therapy; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D015174:Epidural Neoplasms / Q000191:economics / Q000556:secondary* / Q000628:therapy; D017048:Health Care Costs; D006801:Humans; D008134:Long-Term Care; D009010:Monte Carlo Method; D019635:Neurosurgical Procedures / Q000191:economics* / Q000706:statistics & numerical data; D009864:Ontario; D011379:Prognosis; D019057:Quality-Adjusted Life Years; D011878:Radiotherapy / Q000191:economics* / Q000706:statistics & numerical data; D013117:Spinal Cord Compression / Q000191:economics* / Q000628:therapy*