title: Cost-Effectiveness Analysis of Elective Neck Dissection in Patients With Clinically Node-Negative Oral Cavity Cancer.
abstract: Purpose Recently, a large randomized trial found a survival advantage among patients who received elective neck dissection in conjunction with primary surgery for clinically node-negative oral cavity cancer compared with those receiving primary surgery alone. However, elective neck dissection comes with greater upfront cost and patient morbidity. We present a cost-effectiveness analysis of elective neck dissection for the initial surgical management of early-stage oral cavity cancer. Methods We constructed a Markov model to simulate primary, adjuvant, and salvage therapy; disease recurrence; and survival in patients with T1/T2 clinically node-negative oral cavity squamous cell carcinoma. Transition probabilities were derived from clinical trial data; costs (in 2015 US dollars) and health utilities were estimated from the literature. Incremental cost-effectiveness ratios, expressed as dollar per quality-adjusted life-year (QALY), were calculated with incremental cost-effectiveness ratios less than $100,000/QALY considered cost effective. We conducted one-way and probabilistic sensitivity analyses to examine model uncertainty. Results Our base-case model found that over a lifetime the addition of elective neck dissection to primary surgery reduced overall costs by $6,000 and improved effectiveness by 0.42 QALYs compared with primary surgery alone. The decrease in overall cost despite the added neck dissection was a result of less use of salvage therapy. On one-way sensitivity analysis, the model was most sensitive to assumptions about disease recurrence, survival, and the health utility reduction from a neck dissection. Probabilistic sensitivity analysis found that treatment with elective neck dissection was cost effective 76% of the time at a willingness-to-pay threshold of $100,000/QALY. Conclusion Our study found that the addition of elective neck dissection reduces costs and improves health outcomes, making this a cost-effective treatment strategy for patients with early-stage oral cavity cancer.
authors.affiliation: All authors: University of California, San Diego, San Diego, California.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Acevedo
authors.affiliation: All authors: University of California, San Diego, San Diego, California.
authors.forename: Katherine E
authors.initials: KE
authors.lastname: Fero
authors.affiliation: All authors: University of California, San Diego, San Diego, California.
authors.forename: Bayard
authors.initials: B
authors.lastname: Wilson
authors.affiliation: All authors: University of California, San Diego, San Diego, California.
authors.forename: Assuntina G
authors.initials: AG
authors.lastname: Sacco
authors.affiliation: All authors: University of California, San Diego, San Diego, California.
authors.forename: Loren K
authors.initials: LK
authors.lastname: Mell
authors.affiliation: All authors: University of California, San Diego, San Diego, California.
authors.forename: Charles S
authors.initials: CS
authors.lastname: Coffey
authors.affiliation: All authors: University of California, San Diego, San Diego, California.
authors.forename: James D
authors.initials: JD
authors.lastname: Murphy
mesh_terms: D002294:Carcinoma, Squamous Cell / Q000191:economics* / Q000473:pathology / Q000601:surgery*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D006258:Head and Neck Neoplasms / Q000191:economics* / Q000473:pathology / Q000601:surgery*; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008207:Lymphatic Metastasis; D008390:Markov Chains; D018803:Models, Economic; D009062:Mouth Neoplasms / Q000191:economics* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D037981:Neck Dissection / Q000191:economics* / Q000706:statistics & numerical data*; D009367:Neoplasm Staging; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic / Q000191:economics / Q000706:statistics & numerical data; D000077195:Squamous Cell Carcinoma of Head and Neck; D014481:United States / Q000453:epidemiology