Cost-effectiveness of para-aortic lymphadenectomy before chemoradiotherapy in locally advanced cervical cancer.
OBJECTIVE
To evaluate the cost-effectiveness of nodal staging surgery before chemoradiotherapy (CRT) for locally advanced cervical cancer in the era of positron emission tomography/computed tomography (PET/CT).


METHODS
A modified Markov model was constructed to evaluate the cost-effectiveness of para-aortic staging surgery before definite CRT when no uptake is recorded in the para-aortic lymph nodes (PALN) on PET/CT. Survival and complication rates were estimated based on the published literature. Cost data were obtained from the Korean Health Insurance Review and Assessment Service. Strategies were compared using an incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed, including estimates for the performance of PET/CT, postoperative complication rate, and varying survival rates according to the radiation field.


RESULTS
We compared two strategies: strategy 1, pelvic CRT for all patients; and strategy 2, nodal staging surgery followed by extended-field CRT when PALN metastasis was found and pelvic CRT otherwise. The ICER for strategy 2 compared to strategy 1 was $19,505 per quality-adjusted life year (QALY). Under deterministic sensitivity analyses, the model was relatively sensitive to survival reduction in patients who undergo pelvic CRT alone despite having occult PALN metastasis. A probabilistic sensitivity analysis demonstrated the robustness of the case results, with a 91% probability of cost-effectiveness at the willingness-to-pay thresholds of $60,000/QALY.


CONCLUSIONS
Nodal staging surgery before definite CRT may be cost-effective when PET/CT imaging shows no evidence of PALN metastasis. Prospective trials are warranted to transfer these results to guidelines.
Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea.
Jung Yun
JY
Lee
Institute of Health and Environment, Seoul National University Graduate School of Public Health, Seoul, Korea.
Younhee
Y
Kim
Department of Health Policy and Management, Seoul National University Graduate School of Public Health, Seoul, Korea.
Tae Jin
TJ
Lee
Korean Health Promotion Foundation, Seoul, Korea.
Yong Woo
YW
Jeon
Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea.
Kidong
K
Kim
Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea.
Hyun Hoon
HH
Chung
Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea. khjae@ snu.ac.kr.
Hak Jae
HJ
Kim
Department of Family Medicine, Seoul National University College of Medicine, Seoul, Korea.
Sang Min
SM
Park
Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea.
Jae Weon
http://orcid.org/0000-0003-1835-9436
JW
Kim
D059248:Chemoradiotherapy / Q000191:economics*; D003131:Combined Modality Therapy / Q000191:economics; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000191:economics; D008197:Lymph Node Excision / Q000191:economics* / Q000379:methods; D008207:Lymphatic Metastasis; D008390:Markov Chains; D064847:Multimodal Imaging / Q000191:economics; D009367:Neoplasm Staging; D049268:Positron-Emission Tomography / Q000191:economics; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D014057:Tomography, X-Ray Computed / Q000191:economics; D002583:Uterine Cervical Neoplasms / Q000191:economics* / Q000628:therapy
Chemoradiotherapy; Cost-Benefit Analysis; Postoperative Complications; Quality-Adjusted Life Years; Uterine Cervical Neoplasms