title: Cost-Effectiveness Analysis of Preoperative Versus Postoperative Radiation Therapy in Extremity Soft Tissue Sarcoma.
abstract: Surgery combined with radiation therapy (RT) is the cornerstone of multidisciplinary management of extremity soft tissue sarcoma (STS). Although RT can be given in either the preoperative or the postoperative setting with similar local recurrence and survival outcomes, the side effect profiles, costs, and long-term functional outcomes are different. The aim of this study was to use decision analysis to determine optimal sequencing of RT with surgery in patients with extremity STS.
  
  
  
  A cost-effectiveness analysis was conducted using a state transition Markov model, with quality-adjusted life years (QALYs) as the primary outcome. A time horizon of 5 years, a cycle length of 3 months, and a willingness-to-pay threshold of $50,000/QALY was used. One-way deterministic sensitivity analyses were performed to determine the thresholds at which each strategy would be preferred. The robustness of the model was assessed by probabilistic sensitivity analysis.
  
  
  
  Preoperative RT is a more cost-effective strategy ($26,633/3.00 QALYs) than postoperative RT ($28,028/2.86 QALYs) in our base case scenario. Preoperative RT is the superior strategy with either 3-dimensional conformal RT or intensity-modulated RT. One-way sensitivity analyses identified the relative risk of chronic adverse events as having the greatest influence on the preferred timing of RT. The likelihood of preoperative RT being the preferred strategy was 82% on probabilistic sensitivity analysis.
  
  
  
  Preoperative RT is more cost effective than postoperative RT in the management of resectable extremity STS, primarily because of the higher incidence of chronic adverse events with RT in the postoperative setting.
authors.affiliation: Department of Oncology, Queen's University, Kingston, Ontario, Canada.
authors.forename: Xuanlu M
authors.initials: XM
authors.lastname: Qu
authors.affiliation: Department of Radiation Oncology, London Health Sciences Center, London, Ontario, Canada.
authors.forename: Alexander V
authors.initials: AV
authors.lastname: Louie
authors.affiliation: Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Ashman
authors.affiliation: Department of General Surgery, Mayo Clinic Arizona, Phoenix, Arizona. Electronic address: wasif.nabil@mayo.edu.
authors.forename: Nabil
authors.initials: N
authors.lastname: Wasif
mesh_terms: D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005121:Extremities; D006801:Humans; D008390:Markov Chains; D011182:Postoperative Care / Q000191:economics; D011300:Preoperative Care / Q000191:economics; D019057:Quality-Adjusted Life Years; D020266:Radiotherapy, Conformal / Q000009:adverse effects / Q000191:economics*; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000191:economics*; D012509:Sarcoma / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery; D012680:Sensitivity and Specificity