title: Avoiding Radical Surgery in Elderly Patients With Rectal Cancer Is Cost-Effective.
abstract: BACKGROUND
  Radical surgery is associated with significant perioperative mortality in elderly and comorbid populations. Emerging data suggest for patients with a clinical complete response after neoadjuvant chemoradiotherapy that a watch-and-wait approach may provide equivalent survival and oncological outcomes.
  
  
  OBJECTIVE
  The purpose of this study was to compare the cost-effectiveness of watch and wait and radical surgery for patients with rectal cancer after a clinical complete response following chemoradiotherapy.
  
  
  METHODS
  Decision analytical modeling and a Markov simulation were used to model long-term costs, quality-adjusted life-years, and cost-effectiveness after watch and wait and radical surgery. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters.
  
  
  METHODS
  A third-party payer perspective was adopted.
  
  
  METHODS
  Patients included in the study were a 60-year-old male cohort with no comorbidities, 80-year-old male cohorts with no comorbidities, and 80-year-old male cohorts with significant comorbidities.
  
  
  METHODS
  Radical surgery and watch-and-wait approaches were studied.
  
  
  METHODS
  Incremental cost, effectiveness, and cost-effectiveness ratio over the entire lifetime of the hypothetical patient cohorts were measured.
  
  
  RESULTS
  Watch and wait was more effective (60-year-old male cohort with no comorbidities = 0.63 quality-adjusted life-years (95% CI, 2.48-3.65 quality-adjusted life-years); 80-year-old male cohort with no comorbidities = 0.56 quality-adjusted life-years (95% CI, 0.52-1.59 quality-adjusted life-years); 80-year-old male cohort with significant comorbidities = 0.72 quality-adjusted life-years (95% CI, 0.34-1.76 quality-adjusted life-years)) and less costly (60-year-old male cohort with no comorbidities = $11,332.35 (95% CI, $668.50-$23,970.20); 80-year-old male cohort with no comorbidities = $8783.93 (95% CI, $2504.26-$21,900.66); 80-year-old male cohort with significant comorbidities = $10,206.01 (95% CI, $2762.014-$24,135.31)) independent of patient cohort age and comorbidity. Consequently, watch and wait was more cost-effective with a high degree of certainty (range, 69.6%-89.2%) at a threshold of $50,000/quality-adjusted life-year.
  
  
  CONCLUSIONS
  Long-term outcomes were derived from modeled cohorts. Analysis was performed for a United Kingdom third-party payer perspective, limiting generalizability to other healthcare contexts.
  
  
  CONCLUSIONS
  Watch and wait is likely to be cost-effective compared with radical surgery. These findings strongly support the discussion of organ-preserving strategies with suitable patients.
authors.affiliation: 1 University Hospital Lewisham, London, United Kingdom 2 Clatterbridge Cancer Centre, Merseyside, United Kingdom 3 Department of Surgery and Cancer, Imperial College London, London, United Kingdom 4 Epidemiology, Trials and Outcome Centre, St. Mark's Hospital, Harrow, United Kingdom 5 National Institute for Health Research, Collaborations for Leadership in Applied Health Research and Care, North West Coast, University of Liverpool, Liverpool, United Kingdom 6 Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom 7 Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom.
authors.forename: Christopher
authors.initials: C
authors.lastname: Rao
authors.forename: Arthur
authors.initials: A
authors.lastname: Sun Myint
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.forename: Omar
authors.initials: O
authors.lastname: Faiz
authors.forename: Antony Paul
authors.initials: AP
authors.lastname: Martin
authors.forename: Brendan
authors.initials: B
authors.lastname: Collins
authors.forename: Fraser McLean
authors.initials: FM
authors.lastname: Smith
mesh_terms: D000369:Aged, 80 and over; D059248:Chemoradiotherapy; D015331:Cohort Studies; D015897:Comorbidity; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D013505:Digestive System Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007349:Insurance, Health, Reimbursement; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D018365:Neoplasm, Residual; D019057:Quality-Adjusted Life Years; D012004:Rectal Neoplasms / Q000191:economics / Q000453:epidemiology / Q000473:pathology / Q000628:therapy*; D012074:Remission Induction; D006113:United Kingdom; D057832:Watchful Waiting / Q000191:economics / Q000706:statistics & numerical data*