title: Cost-Effectiveness of Surgery, Stereotactic Body Radiation Therapy, and Systemic Therapy for Pulmonary Oligometastases.
abstract: Pulmonary oligometastases have conventionally been managed with surgery and/or systemic therapy. However, given concerns about the high cost of systemic therapy and improvements in local treatment of metastatic cancer, the optimal cost-effective management of these patients is unclear. Therefore, we sought to assess the cost-effectiveness of initial management strategies for pulmonary oligometastases.
  
  
  
  A cost-effectiveness analysis using a Markov modeling approach was used to compare average cumulative costs, quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) among 3 initial disease management strategies: video-assisted thoracic surgery (VATS) wedge resection, stereotactic body radiation therapy (SBRT), and systemic therapy among 5 different cohorts of patient disease: (1) melanoma; (2) non-small cell lung cancer adenocarcinoma without an EGFR mutation (NSCLC AC); (3) NSCLC with an EGFR mutation (NSCLC EGFRm AC); (4) NSCLC squamous cell carcinoma (NSCLC SCC); and (5) colon cancer. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to analyze uncertainty with regard to model parameters.
  
  
  
  In the base case, SBRT was cost effective for melanoma, with costs/net QALYs of $467,787/0.85. In patients with NSCLC, the most cost-effective strategies were SBRT for AC ($156,725/0.80), paclitaxel/carboplatin for SCC ($123,799/0.48), and erlotinib for EGFRm AC ($147,091/1.90). Stereotactic body radiation therapy was marginally cost-effective for EGFRm AC compared to erlotinib with an incremental cost-effectiveness ratio of $126,303/QALY. For colon cancer, VATS wedge resection ($147,730/2.14) was the most cost-effective strategy. Variables with the greatest influence in the model were erlotinib-associated progression-free survival (EGFRm AC), toxicity (EGFRm AC), cost of SBRT (NSCLC SCC), and patient utilities (all histologies).
  
  
  
  Video-assisted thoracic surgery wedge resection or SBRT can be cost-effective in select patients with pulmonary oligometastases, depending on histology, efficacy, and tolerability of treatment and patient preferences.
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut. Electronic address: nataniel.lester-coll@yale.edu.
authors.forename: Nataniel H
authors.initials: NH
authors.lastname: Lester-Coll
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Charles E
authors.initials: CE
authors.lastname: Rutter
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Trevor J
authors.initials: TJ
authors.lastname: Bledsoe
authors.affiliation: Department of Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Sarah B
authors.initials: SB
authors.lastname: Goldberg
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Roy H
authors.initials: RH
authors.lastname: Decker
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: James B
authors.initials: JB
authors.lastname: Yu
mesh_terms: D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality / Q000556:secondary* / Q000628:therapy*; D008390:Markov Chains; D019057:Quality-Adjusted Life Years; D016634:Radiosurgery / Q000191:economics*; D020775:Thoracic Surgery, Video-Assisted / Q000191:economics*