title: Cost-effectiveness of treatment strategies for pancreatic head adenocarcinoma and potential opportunities for improvement.
abstract: BACKGROUND
  Generally dismal outcomes have led to a nihilistic attitude toward treating pancreatic cancer, while fiscal constraints have increased scrutiny of treatments costs. Our objective was to compare the cost-effectiveness of various treatment strategies for resectable pancreatic head adenocarcinoma, and to identify opportunities for improved cost effectiveness.
  
  
  METHODS
  A decision model compared 6 strategies: no treatment, radiotherapy only, chemotherapy only, chemotherapy plus radiotherapy, surgery alone, and surgery plus adjuvant therapy. Outcomes and probabilities were identified using the National Cancer Data Base, the American Cancer Society National Surgical Quality Improvement Program, and the literature. Costs were estimated using Medicare payment. Incremental cost-effectiveness ratios (ICERs) were calculated, and sensitivity analyses were performed by varying potentially modifiable parameters of the model. Survival was reported in quality-adjusted life-months (QALMs).
  
  
  RESULTS
  Surgery plus adjuvant therapy, chemotherapy alone, and no treatment were the only viable strategies in terms of cost effectiveness. Surgery plus adjuvant therapy versus no treatment demonstrated an incremental cost-effectiveness ratio (ICER) of $7,663/QALM. Theoretically increasing survival in node-negative, margin-negative patients from 14 to 22 QALMs produced the largest reduction in the ICER for surgery plus adjuvant therapy compared to no treatment ($6,386/QALM), whereas reducing the perioperative mortality from 3 to 1 % had only a marginal effect. The ICER was significantly lower for high-performing centers ($5,991/QALM) than for low-performing centers ($9,144/QALM).
  
  
  CONCLUSIONS
  Surgery plus adjuvant therapy for resectable pancreatic head adenocarcinoma extends survival, but at considerable expense. Significant cost reductions could be realized by improving treatment outcomes to levels of high-performing centers and development of increasingly effective adjuvant therapies.
authors.affiliation: Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Abbott
authors.forename: Ryan P
authors.initials: RP
authors.lastname: Merkow
authors.forename: Scott B
authors.initials: SB
authors.lastname: Cantor
authors.forename: Jason B
authors.initials: JB
authors.lastname: Fleming
authors.forename: Gauri R
authors.initials: GR
authors.lastname: Varadhachary
authors.forename: Christopher
authors.initials: C
authors.lastname: Crane
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
mesh_terms: D000230:Adenocarcinoma / Q000191:economics* / Q000401:mortality / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000191:economics* / Q000401:mortality / Q000628:therapy; D011379:Prognosis; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D015996:Survival Rate; D055815:Young Adult