ASO Author Reflections: What is the Cost-Effective Treatment of Melanoma Patients with a Positive Sentinel Node?
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: What is the Cost-Effective Treatment of Melanoma Patients with a Positive Sentinel Node? Hayley Standage, BS
, and Dale Han, MD, FACS
Division of Surgical Oncology, Oregon Health and Science University, Portland, OR
PAST Melanoma patients with a positive sentinel lymph node (SLN) now have multiple treatment options. Historically, complete lymph node dissection (CLND) was recommended but studies demonstrated no survival benefit for CLND over nodal observation (OBS).1–3 Furthermore, checkpoint inhibitors such as pembrolizumab (PEM) are approved as adjuvant therapy after CLND (CLND-PEM).4 However, positive SLN patients are now being treated with adjuvant PEM without CLND (PEM-Alone), but there are no data on the efficacy of adjuvant PEM without CLND. Moreover, PEM is costly and has potential toxicity. Our current understanding of the most efficacious treatment for positive SLN patients is limited. Therefore, we developed a cost-effectiveness analysis of four treatment options for positive SLN patients to determine the most cost-effective therapy.5 PRESENT OBS was the only cost-effective therapy compared with CLND, CLND-PEM, and PEM-Alone. OBS was the least costly but had the greatest risk for recurrences. CLND and CLND-PEM had lower quality-adjusted life-years (QALYs) and higher costs compared with OBS. The quality-of-life decrement and greater costs in strategies using CLND were primarily due to the rates of lymphedema, which was 24.1% in the CLND and CLND-PEM
Ó Society of Surgical Oncology 2020 First Received: 5 September 2020 Accepted: 10 September 2020 D. Han, MD, FACS e-mail: [email protected]
groups compared with 6.3% in the OBS and PEM-Alone groups. PEM-Alone had the highest QALYs, due to having the lowest recurrence rates as well as a low lymphedema rate, but PEM-Alone was the costliest strategy, with an incremental cost-effectiveness ratio of $1.2 million/QALY. This exceeded the willingness-to-pay threshold of $100,000/QALY. PEM-Alone would be cost effective if the drug cost was reduced to $14,404 from a baseline cost of $128,597 per patient. FUTURE Compared with CLND, CLND-PEM, and PEM-Alone, OBS is a cost-effective strategy in managing melanoma patients with SLN metastases.5 These results should be considered for the development of guidelines and shared decision-making conversations with melanoma patients regarding the treatment of SLN metastases. Moreover, further research is needed with long-term follow-up and survival data because if adjuvant PEM continued to show a consistent survival benefit, the cost of strategies using PEM may become justified. Additional studies are also needed to validate this study’s findings in an actual patient cohort and to assess if PEM-Alone may be cost effective in certain subgroups of positive SLN patients. Finally, the current study was unable to evaluate other types of adjuvant therapy, and the cost-effectiveness of strategies using these other adjuvant therapies should also be assessed.5 DISCLOSURES Hayley Standage and D
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