title: Cost analysis of adjuvant management strategies in early stage (stage I) testicular seminoma.
abstract: BACKGROUND
  Acceptable post-orchiectomy adjuvant therapy strategies for stage I seminoma patients include surveillance, para-aortic radiation therapy (RT), dog-leg RT, and a single cycle of carboplatin. The required follow-up recommendations were amended by the National Comprehensive Cancer Network (NCCN) in 2012. Given a cause-specific survival of nearly 100%, a closer analysis of the reimbursement for each treatment strategy is warranted.
  
  
  METHODS
  NCCN guidelines were used to design treatment plans for each acceptable adjuvant treatment strategy. Follow-up charges were generated for 10 years based on 2012 (version 1.2012; unchanged in current version 1.2013) and 2011 NCCN (version 2.2011) surveillance recommendations. The 2012 Medicare reimbursement rates were used to calculate each treatment strategy and incremental cost-effectiveness ratios to compare the treatment options.
  
  
  RESULTS
  Under the current NCCN follow-up recommendations, the total reimbursements generated over 10 years of surveillance, para-aortic RT, dog-leg RT, and carboplatin were $10,643, $11,678, $9,662, and $10,405, respectively. This is compared with the reimbursements as per the 2011 NCCN recommendations: $20,986, $11,517, $9,394, and $20,365 respectively. Factoring the rates of relapse into a salvage model, observation was found to be more costly and less effective ($-1,831, $-7,318, $-7,010) in the adjuvant management of stage I seminoma patients.
  
  
  CONCLUSIONS
  Based on incremental cost-effectiveness ratios, para-aortic RT, dog-leg RT, and carboplatin are cost-effective options for the treatment of stage I seminoma when compared with observation; however, surveillance could potentially spare as many as 80%-85% of men diagnosed with stage I seminoma from additional therapy after radical inguinal orchiectomy. Such cost and reimbursement analyses are becoming increasingly relevant, but are not meant to usurp sound clinical judgment. Further studies are required to validate these findings.
authors.affiliation: Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX, USA ; Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: John A
authors.initials: JA
authors.lastname: Cox
authors.affiliation: University of Texas Medical Branch School of Medicine, Galveston, TX, USA.
authors.forename: Shefali R
authors.initials: SR
authors.lastname: Gajjar
authors.affiliation: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA.
authors.forename: Thomas B
authors.initials: TB
authors.lastname: Lanni
authors.affiliation: Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX, USA.
authors.forename: Todd A
authors.initials: TA
authors.lastname: Swanson
keywords: adjuvant management; cost analysis; low-stage testicular seminoma