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Stage- and age-adjusted cost-effectiveness analysis of laparoscopic surgery in rectal cancer

Abstract

Background

It has been argued that laparoscopy should be a standard treatment in rectal cancer due to its greater technical complexity. The objective of this study was to conduct a cost-effectiveness analysis to compare laparoscopy with open surgery for rectal cancer adjusting for age and clinical stage.

Methods

A real-world prospective cost-effectiveness cohort study was conducted with data on costs and effectiveness at individual patient level. A “genetic matching” algorithm was used to correct for selection bias. After balancing the sample groups, combined multivariate analysis of total costs and quality-adjusted life years (QALYs) was performed using seemingly unrelated regression (SUR) models. These models were first constructed without interactions and, subsequently, effects of any age-stage interaction were analyzed.

Results

The sample included 601 patients (400 by laparoscopy and 201 by open surgery). Crude cost-effectiveness analysis indicated that overall laparoscopy was cheaper and associated with higher QALYs. The SUR models without interactions showed that while laparoscopy remained dominant, the incremental effectiveness decreased to the point that it offered no statistically significant benefits over open surgery. In the subgroup analysis, at advanced stages of the disease, although none of the coefficients were significant, the mean incremental effectiveness (QALYs value) for laparoscopy was positive in younger patients and negative in older patients. Further, for advanced stages, the mean cost of open surgery was lower in both age subgroups but differences did not reach statistical significance. In early stages, laparoscopy cost was significantly lower in the subgroup younger than 70 and higher in the older subgroup.

Conclusions

The cost-effectiveness of laparoscopy in surgery for rectal cancer justifies this being the standard surgical procedure in young patients and those at initial stages. The choice of procedure should be discussed with patients who are older and/or in advanced stages of the disease.

Trial registration ClinicalTrials.gov Identifier: NCT02488161.

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Acknowledgements

We would like to acknowledge the help of Ideas Need Communicating Language Services in improving the use of English in the manuscript.

Funding

This work was supported in part by grants from the Fondo de Investigación Sanitaria (PS09/00314, PS09/00910, PS09/00746, PS09/00805, PI09/90460, PI09/90490, PI09/90397, PI09/90453, PI09/90441); Department of Health of the Basque Country (2010111098); KRONIKGUNE—Centro de Investigación en Cronicidad (KRONIK 11/006); and the European Regional Development Fund. These institutions had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the paper for publication.

Author information

JMQ and JM conceived and designed the research. The REDISSEC CARESS-CCR Investigators Group acquired, analyzed, and interpreted the data. JM, AA, OI, and AA performed the statistical analyses and interpreted the data. SL, NG, MB, AE, and MR designed the research, interpreted the data, handled funding and supervision, and critically revised the manuscript. JM, JMQ, AA, OI, and AA drafted the manuscript. All authors revised the manuscript for important intellectual content and approved the final manuscript.

Correspondence to Javier Mar.

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Disclosures

Javier Mar MD, Ane Anton-Ladislao M.Sc., Oliver Ibarrondo Ph.D., Arantzazu Arrospide Ph.D., Santiago Lázaro MD, Nerea Gonzalez Ph.D., Marisa Bare MD, Antonio Escobar MD, Maximino Redondo MD and, José M. Quintana MD have no conflicts of interest or financial ties to disclose.

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Mar, J., Anton-Ladislao, A., Ibarrondo, O. et al. Stage- and age-adjusted cost-effectiveness analysis of laparoscopic surgery in rectal cancer. Surg Endosc 34, 1167–1176 (2020). https://doi.org/10.1007/s00464-019-06867-y

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Keywords

  • Rectal cancer
  • Laparoscopy
  • Open surgery
  • Cost-effectiveness
  • Stage
  • Age