Cost effectiveness analysis of the management of potentially resectable pancreatic cancer

Bradley, A. and Van Der Meer, R. and McKay, C. (2019) Cost effectiveness analysis of the management of potentially resectable pancreatic cancer. In: BMJ International Forum on Quality and Safety in Healthcare, 2019-03-27 - 2019-03-29, Scottish Exhibition & Conference Centre.

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Abstract

1) Conflicts of interest: None. 2) Context: The work was performed at the University of Strathclyde Business School, Management Science Department. It focused on patients with resectable, borderline resectable and locally advanced pancreatic cancer at time of presentation. 3) Problem: Neoadjuvant therapy has emerged as an alternative treatment strategy for potentially resectable pancreatic cancer. This approach was partly driven by the realisation that in the traditional surgery first approach, up to 50% of patients failed to receive adjuvant therapy due to early disease reoccurrence, post-operative complications or decline in function hence rendering costly and high-risk surgery ultimately futile. Potential benefits of neoadjuvant approach include: elimination of micrometastases, increased likelihood of obtaining multimodal treatment and R0 resection and identifying patients with more aggressive tumours prior to surgery that would be of little benefit to their duration or quality of survival time. Currently upfront surgery and adjuvant therapy is recommended for cases of pancreatic cancer that are resectable at presentation. Neoadjuvant therapy is widely supported for locally advanced and borderline cases. This aim of this study was to perform cost-effectiveness analysis comparing neoadjuvant and surgery first approach to the management of potentially resectable pancreatic cancer. 4) Assessment of problem and analysis of its causes: Systematic reviews and meta-analysis demonstrated a current lack of studies offering head-to-head comparison between both treatment pathways. These findings were disseminated to the pancreatic cancer multi-disciplinary-team at research meetings. 5) Intervention: To improve the delivery of care to pancreatic cancer patients with potentially resectable disease the UK’s first cost-effectiveness analysis of neoadjuvant therapy versus upfront surgery for potentially resectable pancreatic cancer was undertaken using a Markov model method. 6) Strategy for change: Firstly, the Markov model was populated with transition probabilities calculated from a pooled proportion meta-analysis of phase II/III trials and randomised controlled trials using Freeman-Tukey arcsine square root transformation under random effects model to account for heterogeneity. The structure of the Markov model was agreed with the West of Scotland Pancreatic Unit multi-disciplinary-team before being used to perform cost-effectiveness analysis. 7) Measurement of improvement: Effectiveness was measured as quality-adjusted-life-months (QALMs). Each Markov cycle was 1month with a total follow-up time of 60 cycles or until death. Discount for cost and benefit set at 3.5% as per NICE guidelines. Model uncertainties were tested through one and two-way deterministic and probabilistic Monte Carlo sensitivity analysis. Surgery first pathway gave 17.59 QALMs at a cost effectiveness ratio of £5582.85. Neoadjuvant pathway gave 15.46 QALMs at a cost effectiveness ratio of £4311.02. This meant the surgery first had an incremental effectiveness of 2.13 QALMs with an incremental cost effectiveness ratio of £14804.81. When willingness-to-pay was set at £30,000 per QALY as per NICE guidelines, neoadjuvant pathway was then most cost-effective pathway for treatment of patients with potentially resectable pancreatic cancer. 8) Effects of changes: It appears that neoadjuvant therapy saves money by allowing time to filter out more aggressive tumours hence avoiding ultimately futile surgery with associated costs and risks. The benefits of this work are that money could be saved and reinvested into further improving pancreatic cancer services, particularly in streamlining services so that those who stand to benefit most from surgery are fast tracked to surgery. This work will also form the basis of future work into personalised predictive medicine to facilitate better patient counselling and shared decision-making with patients when choosing between treatment options. 9) Lessons learnt: Costs and benefits of cancer treatment are complex with quality as well as quantity of survival time holding great importance. However, quality-of-life data for pancreatic cancer is limited and should be the focus of further research. Neoadjuvant pathway was more cost-effective, but this depended on receiving multimodal treatment in either pathway. Ultimately this highlights the need moving towards personalised predictive medicine to support shared decision-making in research and practice so that the most effective treatment can be targeted at individual level. 10) Messages for others: Cost-effectiveness analysis adds an important dimension to the debate about competing treatment options for potentially resectable pancreatic cancer. Costs and benefits in cancer treatment are multifaceted and complex requiring greater patient and carer input in future research mandating a focus on achieving personalised predictive medicine in research to support shared clinical decision-making and better streamlining of services to meet individual patient needs. 11) Involvement of patients, carers or family members in the project: The next phase of this project will involve patients and carers participation to explore quality-of-life impact of interventions and impact of statistical models in supporting shared decision-making from the patient’s perspective. 12) Ethics Approval: Not applicable

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