Active surveillance is cost-effective compared with standard surgery among esophageal cancer patients with complete clinical response after neoadjuvant chemoradiotherapy

1. Active surveillance was cost-effective over 5 years compared with standard surgery in patients with esophageal cancer and complete clinical response after neoadjuvant chemoradiotherapy.

Evidence Rating Level: 1 (Excellent)

Active surveillance for patients with esophageal cancer and a complete clinical response (CCR) after neoadjuvant chemoradiotherapy (nCRT) is noninferior to standard surgery for 2-year survival. It is unclear whether active surveillance is cost-effective compared with standard surgery among these patients. This study thus examined the cost-effectiveness of active surveillance vs standard surgery after nCRT. This was a secondary analysis of a randomized clinical trial in the Netherlands that enrolled patients with esophageal cancer who achieved a CCR after nCRT between November 8, 2017, and January 17, 2021, with follow-up for up to 5 years. Patients underwent either active surveillance or standard esophagectomy, according to cluster randomization. Active surveillance involved repeated clinical response evaluations and surgery as needed when locoregional regrowth occurred. Standard surgery involved immediate surgery after determination of CCR. The primary outcome was incremental cost-effectiveness of active surveillance vs standard surgery and quality-adjusted life-years (QALYs) up to 5 years. Among 309 patients in the study cohort, 198 were in the active surveillance group (median age, 69 years [IQR, 63-74 years]; 156 men [79%]) and 111 were in the standard surgery group (median age, 68 years [IQR, 61-73 years]; 86 men [77%]). At 5 years, patients in the active surveillance group had a mean of 2.99 QALYs (95% CI, 2.73-3.26) vs 2.88 QALYs (95% CI 2.69-3.06) in the standard surgery group. Active surveillance resulted in a 0.11 QALY gain (95% CI, −0.10 to 0.33), although the difference was not significant. The mean costs for active surveillance were €8374 lower (95% CI, €1792-€15 355) compared with standard surgery. Active surveillance was found to be cost-effective, with the mean incremental net monetary benefit (iNMB) being €17 568 (95% CI, −€725 to €37 497) at a willingness-to-pay threshold of €80 000 per QALY. Overall, this study found that among patients with esophageal cancer achieving a CCR after nCRT, active surveillance was cost-effective over 5-years compared with standard surgery. These findings support broader implementation of active surveillance to reduce health care costs while maintaining comparable health outcomes.

Click here to read this study in JAMA Network Open

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