What is the Cost-Effective Treatment for Melanoma Patients with a Positive Sentinel Node?
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ORIGINAL ARTICLE – MELANOMA
What is the Cost-Effective Treatment for Melanoma Patients with a Positive Sentinel Node? Hayley Standage, BS1, Alyssa R. Hersh, MD, MPH2, Aaron Caughey, MD, PHD2, Matthew Taylor, MD3, John Vetto, MD1, and Dale Han, MD, FACS1 1
Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR; Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR; 3Earle A Chiles Research Institute, Providence Cancer Institute, Portland, OR
2
ABSTRACT Background. Survival for positive sentinel lymph node (SLN) patients does not differ between completion lymph node dissection (CLND) and nodal observation (OBS). However, treating these patients with CLND and checkpoint inhibitors, such as pembrolizumab (PEM), improves outcomes. This study evaluated the cost-effectiveness of OBS, CLND, and CLND with PEM (CLND-PEM) treatments. Methods. A Markov model was designed to simulate treatment for a theoretical cohort of 1000 positive SLN patients per therapy with a 5-year follow-up period. An intervention was cost-effective if its incremental cost-effectiveness ratio among therapies was below the willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY). Results. Compared with CLND or CLND-PEM, OBS resulted in fewer lymphedema cases but in more disease recurrences. Compared with OBS, CLND had higher costs and lower QALYs. Although CLND-PEM had a lower number of recurrences and deaths than OBS or CLND, it had higher costs and lower QALYs than OBS, and thus was not cost-effective. However, with the effects of CLND
Presented virtually at the Society of Surgical Oncology 2020 International Conference on Surgical Cancer Care, on August 17, 2020. Ó Society of Surgical Oncology 2020 First Received: 17 April 2020 Accepted: 25 August 2020 D. Han, MD, FACS e-mail: [email protected]
from CLND-PEM removed, allowing evaluation of PEM effects alone (PEM alone), the resulting QALYs were the highest, but PEM alone still was not cost-effective compared with OBS ($1.2 million per QALY). By reducing the drug cost to less than $14,404 per patient, PEM alone would become cost-effective. Conclusions. Compared with CLND, CLND-PEM, and PEM alone, OBS was cost-effective for managing positive SLN patients. Although CLND-PEM and PEM alone result in fewer recurrences and deaths, these therapies were not cost-effective due to the quality-of-life decrement of CLND and the current high drug cost of PEM.
For patients presenting with clinically localized melanoma, sentinel lymph node biopsy (SLNB) is recommended for nodal staging, particularly for patients with an intermediate-thickness primary tumor.1–4 However, the management of positive SLN patients has undergone a paradigm shift. In the past, completion lymph node dissection (CLND) was recommended for positive SLN patients, but the benefit of CLND was questioned based on retrospective studies.5,6 Subsequently, the Multicenter Selective Lymphadenectomy Trial (MSLT)-II and the DeCOG-SLT evaluate
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