title: Cost-Effectiveness Analysis of Chemoradiation Therapy Versus Transoral Robotic Surgery for Human Papillomavirus-Associated, Clinical N2 Oropharyngeal Cancer.
abstract: OBJECTIVE
  To perform a cost-effectiveness analysis of primary chemoradiation therapy (CRT) versus transoral robotic surgery (TORS) for clinical N2, human papillomavirus (HPV)-positive oropharyngeal carcinoma.
  
  
  METHODS
  We developed a Markov model to describe the health states after treatment with CRT or TORS, followed by adjuvant radiation therapy or CRT in the presence of high-risk pathology (positive margins or extracapsular extension). Outcomes, toxicities, and costs were extracted from the literature. One-way sensitivity analyses (SA) were performed over a wide range of parameters, as were 2-way SA between the key variables. Probabilistic SA and value of information studies were performed over key parameters.
  
  
  RESULTS
  The expected quality-adjusted life years (QALYs)/total costs for CRT and TORS were 7.31/$50,100 and 7.29/$62,200, respectively, so that CRT dominated TORS. In SA, primary CRT was almost always cost-effective up to a societal willingness-to-pay of $200,000/QALY, unless the locoregional recurrence risk after TORS was 30% to 50% lower, at which point it became cost effective at a willingness-to-pay of $50-100,000/QALY. Probabilistic SA confirmed the importance of locoregional recurrence risk, and the value of information in precisely knowing this parameter was more than $7M per year. If the long-term utility after TORS was 0.03 lower than CRT, CRT was cost-effective over nearly any assumption.
  
  
  CONCLUSIONS
  Under nearly all assumptions, primary CRT was the cost-effective therapy for HPV-associated, clinical N2 OPC. However, in the hypothetical event of a large relative improvement in LRR with surgery and equivalent long-term utilities, primary TORS would become the higher-value treatment, arguing for prospective, comparative study of the 2 paradigms.
authors: Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address: david.sher@utsouthwestern.edu.
authors: David J
authors: DJ
authors: Sher
authors: Section of Medical Oncology, Rush University Medical Center, Chicago, Illinois.
authors: Mary Jo
authors: MJ
authors: Fidler
authors: Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
authors: Roy B
authors: RB
authors: Tishler
authors: Department of Otolaryngology, Rush University Medical Center, Chicago, Illinois.
authors: Kerstin
authors: K
authors: Stenson
authors: Department of Otolaryngology, Rush University Medical Center, Chicago, Illinois.
authors: Samer
authors: S
authors: al-Khudari
mesh_terms: D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000628:therapy* / Q000821:virology; D059248:Chemoradiotherapy / Q000191:economics*; D003362:Cost-Benefit Analysis; D006801:Humans; D008390:Markov Chains; D009364:Neoplasm Recurrence, Local; D009959:Oropharyngeal Neoplasms / Q000473:pathology / Q000628:therapy* / Q000821:virology; D027383:Papillomaviridae; D019057:Quality-Adjusted Life Years; D018714:Radiotherapy, Adjuvant; D065287:Robotic Surgical Procedures / Q000191:economics* / Q000379:methods; D012680:Sensitivity and Specificity