A rapid review of the cost-effectiveness of alternative interventions across cancer care pathways: radiotherapy and surgery

Introduction: Based on a scope determined by the Department of Health, a rapid review was undertaken to explore the existing literature describing the cost-effectiveness of surgical and/or radiotherapy interventions in patients with (i) breast cancer, (ii) colorectal cancer, (iii) prostate cancer, (iv) cervical cancer and (v) head and neck cancer. The aim was to assess the relevance of the cost-effectiveness evidence to current UK policy and decision making.

Methods: Full systematic literature searches were undertaken with tiered criteria used for inclusion of studies into the eight reviews. Inclusion criteria were based on the relevance of studies to policy decision making. Cost-effectiveness studies analysing the incremental cost per quality adjusted life year (QALY) or cost per life year (LY) met the initial, preferred criteria. Cost per QALY analyses enable comparison across other disease areas and reflect the methods guidance for the NICE reference case. The studies in each cancer area were sub-grouped into clinically meaningful categories where possible and were assessed in terms of their alignment with the NICE reference case. Relevance of the interventions in terms of current UK clinical practice was informed by clinical experts.

Findings: Almost 9,000 studies were identified and screened for inclusion. Of these, 45 studies met the initial criteria for inclusion in the reviews. Applying the NICE threshold value of £30k per QALY at the time of publication, irrespective of setting or adherence to the NICE methods guide:

Breast cancer, surgery, based on three non-UK based studies:

• breast conserving surgery plus axillary mode dissection compared to modified radical mastectomy would be considered cost-effective (£12.8k per QALY)

• breast conservation surgery with radiation therapy compared to mastectomy would not be considered cost-effective. There are multiple reasons for this including cosmesis, patient preferences and the added cost of reconstruction which is employed after mastectomy in over 20% of all cases. (This comparison is no longer appropriate in the current clinical context as it is now current practice, with rare exceptions, for radiation to be administered after conservation therapy)

Breast cancer, radiotherapy, based on one UK study and 13 non-UK studies:

• whole breast radiotherapy following breast conservation is generally considered cost-effective (range £3.0k to £23k per QALY), but further studies are required to identify a very 3

low risk group of patients who derive minimal benefit and can therefore safely avoid radiotherapy (cost per QALY much greater than threshold in low risk patients)

• post-mastectomy radiotherapy is cost-effective in patients at higher risk of recurrence but the definition of this level of risk is not clear (£19k per QALY to dominating (lower costs and larger benefits))

• partial breast radiotherapy is still experimental and there is currently insufficient mature outcome data from which to draw conclusions about the cost-effectiveness of this intervention

Colorectal cancer, surgery, based on two UK studies and three non UK studies:

• comparing laparoscopic surgery to open surgery, although there is a large amount of uncertainty in the results reported (ranging from dominating (lower costs and larger benefits) to dominated (higher costs and lower benefits) based on the two UK studies), laparoscopic surgery is currently recommended in the UK due to the potential short-term quality of life benefits

• emergency colonic stenting dominated emergency surgery in patients with emergent, malignant left colonic obstruction

• surgical resection with both diagnostic/palliative surgery is dominated by non-surgical treatment

Colorectal cancer, radiotherapy, based on two non UK based studies:

• preoperative radiotherapy followed by surgery compared to surgery alone would be considered cost-effective (range £2.3k to £15.7k per QALY)

Prostate cancer, surgery, based on two UK studies and four non-UK based studies:

• radical prostatectomy in patients with localised prostate cancer was dominated by watchful waiting based on a UK study

• radical prostatectomy would be considered cost-effective in patients with localised prostate cancer compared to watchful watching only when side-effects of the surgical technique are excluded (£8k per QALY)

Prostate cancer, radiotherapy, based on one UK study and nine non-UK studies:

• cryotherapy compared to traditional radiotherapy and radical prostatectomy would not be considered cost-effective based on the UK study (over £100k per QALY) 4

• brachytherapy and 3D conformal radiation would be considered cost-effective compared to traditional radiotherapy and radical prostatectomy (£0.7k to £11.7k per QALY)

• intensity modulated radiotherapy compared to 3D conformal radiation would be considered cost-effective (£10.5 to £25k per QALY)

• radiotherapy plus hormone therapy compared to just radiotherapy in locally advanced patients would be considered cost-effective (lower costs and larger benefits)

• single or multi-fraction radiotherapy compared to palliative treatments (pain medication or chemotherapy) in hormone-refractory prostate cancer patients would be considered cost-effective (£4.2k to £22.4)

Cervical cancer, radiotherapy: Although 13 full papers were retrieved for review, none satisfied the initial or relaxed inclusion criteria.

Head and neck cancer, radiotherapy, based on three non-UK studies:

• trans oral CO2 laser excision dominated external beam radiation for patients with T1 glottic carcinoma (lower costs and higher QALY)

• accelerated fractionated radiotherapy with concomitant boost, and hyper fractionated radiotherapy would be considered cost-effective compared to standard fractionated radiotherapy in patients with local advanced head and neck cancer (£8.8k to £15k per QALY) proton therapy would be considered cost-effective compared to conventional radiotherapy (£3.1k per QALY)

Caveats: The results presented here should be treated with caution as there are some fundamental issues which limit the generalisability of the results to current policy decision making in the UK. In particular, the relevance to current UK clinical practice is questionable for some indications, very few of the studies were based in the UK and international costs of interventions and health care do not generally transfer to the UK; the clinical evidence used in the majority of the studies is dated and rarely synthesised to capture all the uncertainty associated with the particular interventions under evaluation.