title: The cost-effectiveness of neoadjuvant chemoradiation is superior to a surgery-first approach in the treatment of pancreatic head adenocarcinoma.
abstract: BACKGROUND
  In treating pancreatic cancer, there is no clearly defined optimal sequence of chemotherapy, radiation therapy and surgery. Therefore, cost-effectiveness should be considered. The objective of this study was to compare cost and outcomes between a surgery-first approach versus neoadjuvant chemoradiation followed by surgery for resectable pancreatic head cancer.
  
  
  METHODS
  A decision analytic model was constructed to compare the 2 approaches. Data from the National Cancer Database, National Surgical Quality Improvement Program, and literature populated the surgery-first arm. Data from our prospectively maintained institutional pancreatic cancer database populated the neoadjuvant arm. Costs were estimated by Medicare payment (2011 U.S. dollars). Survival was reported in quality-adjusted life-months (QALMs).
  
  
  RESULTS
  The neoadjuvant chemoradiation arm consisted of 164 patients who completed preoperative therapy. Of these, 36 (22 %) did not proceed to surgery; 12 (7 %) underwent laparotomy but had unresectable disease; and 116 (71 %) underwent definitive resection. The surgery-first approach cost $46,830 and yielded survival of 8.7 QALMs; the neoadjuvant chemoradiation approach cost $36,583 and yielded survival of 18.8 QALMs. In the neoadjuvant arm, costs and survival times for patients not undergoing surgery, those with unresectable disease at laparotomy, and those completing surgery were $12,401 and 7.7 QALMs, $20,380 and 7.1 QALMs, and $45,673 and 23.4 QALMs, respectively.
  
  
  CONCLUSIONS
  Neoadjuvant chemoradiation for pancreatic cancer identifies patients with early metastases or poor performance status, who can be spared an ineffective or prohibitively morbid operation, and is associated with improved survival at significantly lower cost than a surgery-first approach. Neoadjuvant chemoradiation followed by surgery is a strategy that provides more cost-effective care than a surgery-first approach.
authors: Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.
authors: Daniel E
authors: DE
authors: Abbott
authors: Ching-Wei David
authors: CW
authors: Tzeng
authors: Ryan P
authors: RP
authors: Merkow
authors: Scott B
authors: SB
authors: Cantor
authors: George J
authors: GJ
authors: Chang
authors: Matthew Harold
authors: MH
authors: Katz
authors: David J
authors: DJ
authors: Bentrem
authors: Karl Y
authors: KY
authors: Bilimoria
authors: Christopher H
authors: CH
authors: Crane
authors: Gauri R
authors: GR
authors: Varadhachary
authors: James L
authors: JL
authors: Abbruzzese
authors: Robert A
authors: RA
authors: Wolff
authors: Jeffrey E
authors: JE
authors: Lee
authors: Douglas B
authors: DB
authors: Evans
authors: Jason B
authors: JB
authors: Fleming
mesh_terms: D000230:Adenocarcinoma / Q000191:economics* / Q000401:mortality / Q000628:therapy; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D059248:Chemoradiotherapy; D017024:Chemotherapy, Adjuvant; D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005500:Follow-Up Studies; D006801:Humans; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000191:economics* / Q000401:mortality / Q000628:therapy; D011379:Prognosis; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D018714:Radiotherapy, Adjuvant; D015996:Survival Rate