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CC BY-NC-ND 4.0 · Endosc Int Open 2021; 09(10): E1512-E1519
DOI: 10.1055/a-1522-8762
Original article

Cost comparisons of endoscopic and surgical resection of stage T1 rectal cancer

Victoria Arthursson
1   Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
,
Roberto Rosén
1   Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
,
Jenny M. Norlin
2   The Swedish Institute for Health Economics, Lund, Sweden
,
Katarina Gralén
2   The Swedish Institute for Health Economics, Lund, Sweden
,
Ervin Toth
3   Department of Clinical Sciences, Section of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
,
Ingvar Syk
1   Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
,
Henrik Thorlacius
1   Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
,
Carl-Fredrik Rönnow
1   Department of Clinical Sciences, Malmö, Section of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
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Abstract

Background and study aims Management of T1 rectal cancer is complex and includes several resection methods, making cost comparisons challenging. The aim of this study was to compare costs of endoscopic and surgical resection and to investigate hypothetical cost scenarios for the treatment of T1 rectal cancer.

Patients and methods Retrospective population-based cost minimization study on prospectively collected data on T1 rectal cancer patients treated using endoscopic submucosal dissection (ESD), transanal endoscopic microsurgery (TEM), open, laparoscopic, or robotic resection, in Skåne County, Sweden (2011–2017). The hypothetical cost scenarios were based on the distribution of high-risk features of lymph node metastases in a national cohort (2009–2017).

Results Eighty-five patients with T1 RC undergoing ESD (n = 16), TEM (n = 17), open (n = 35), laparoscopic (n = 9), and robotic (n = 8) resection were included. ESD had a total 1-year cost of 5165 € and was significantly (P < 0.05) less expensive compared to TEM (14871€), open (21 453 €), laparoscopic (22 488 €) and robotic resection (26 562 €). Risk factors for lymph node metastases were seen in 68 % of 779 cases of T1 rectal cancers included in the national cohort. The hypothetical scenario of performing ESD on all T1 RC had the lowest total 1-year per patient cost compared to all other alternatives.

Conclusions This is the first study analyzing total 1-year costs of endoscopic and surgical methods to resect T1 rectal cancer, which showed that the cost of ESD was significantly lower compared to TEM and surgical resection. In fact, based on hypothetical cost scenarios, ESD is still justifiable from a cost perspective even when all high-risk cases are followed by surgery in accordance to guidelines.



Publication History

Received: 25 January 2021

Accepted: 19 May 2021

Article published online:
16 September 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Fitzmaurice C, Allen C. Global Burden of Disease Cancer Collaboration. et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol 2017; 3: 524-548
    CrossrefPubMedGoogle Scholar
  • 2 Lacy AM, Garcia-Valdecasas JC, Delgado S. et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 2002; 359: 2224-2229
    CrossrefPubMedGoogle Scholar
  • 3 Fleshman J, Sargent DJ, Green E. et al. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 2007; 246: 655-662 discussion 662-654
    CrossrefPubMedGoogle Scholar
  • 4 Memon S, Heriot AG, Murphy DG. et al. Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis. Ann Surg Oncol 2012; 19: 2095-2101
    CrossrefPubMedGoogle Scholar
  • 5 Al-Najami I, Rancinger CP, Larsen MK. et al. Transanal endoscopic microsurgery for advanced polyps and early cancers in the rectum-Long-term outcome: A STROBE compliant observational study. Medicine 2016; 95: e4732
    CrossrefPubMedGoogle Scholar
  • 6 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Zauber AG, Winawer SJ, O'Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
    CrossrefPubMedGoogle Scholar
  • 8 Kim JB, Lee HS, Lee HJ. et al. Long-term outcomes of endoscopic versus surgical resection of superficial submucosal colorectal cancer. Dig Dis Sci 2015; 60: 2785-2792
    CrossrefPubMedGoogle Scholar
  • 9 Alves A, Panis Y, Mathieu P. et al. Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study. Arch Surg 2005; 140: 278-283 discussion 284
    CrossrefPubMedGoogle Scholar
  • 10 Porter ME. What is value in health care?. N Engl J Med 2010; 363: 2477-2481
    CrossrefPubMedGoogle Scholar
  • 11 Barbash GI, Glied SA. New technology and health care costs--the case of robot-assisted surgery. N Engl J Med 2010; 363: 701-704
    CrossrefPubMedGoogle Scholar
  • 12 Nam MJ, Sohn DK, Hong CW. et al. Cost comparison between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors. Ann Surg Treat Res 2015; 89: 202-207
    CrossrefPubMedGoogle Scholar
  • 13 McCarty TR, Bazarbashi AN, Hathorn KE. et al. Endoscopic submucosal dissection (ESD) versus transanal endoscopic microsurgery (TEM) for treatment of rectal tumors: a comparative systematic review and meta-analysis. Surg Endosc 2020; 34: 1688-1695
    CrossrefPubMedGoogle Scholar
  • 14 Wang S, Gao S, Yang W. et al. Endoscopic submucosal dissection versus local excision for early rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2016; 20: 1-9
    CrossrefPubMedGoogle Scholar
  • 15 Park SU, Min YW, Shin JU. et al. Endoscopic submucosal dissection or transanal endoscopic microsurgery for nonpolypoid rectal high grade dysplasia and submucosa-invading rectal cancer. Endoscopy 2012; 44: 1031-1036
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Silva-Velazco J, Dietz DW, Stocchi L. et al. Considering value in rectal cancer surgery: an analysis of costs and outcomes based on the open, laparoscopic, and robotic approach for proctectomy. Ann Surg 2017; 265: 960-968
    CrossrefPubMedGoogle Scholar
  • 17 Law R, Das A, Gregory D. et al. Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis. Gastrointest Endosc 2016; 83: 1248-1257
    CrossrefPubMedGoogle Scholar
  • 18 Fukami N. Surgery versus endoscopic mucosal resection versus endoscopic submucosal dissection for large polyps: making sense of when to use which approach. Gastrointest Endosc Clin N Am 2019; 29: 675-685
    CrossrefPubMedGoogle Scholar
  • 19 Maslekar S, Pillinger SH, Sharma A. et al. Cost analysis of transanal endoscopic microsurgery for rectal tumours. Colorectal Dis 2007; 9: 229-234
    CrossrefPubMedGoogle Scholar
  • 20 Brusselaers N, Lagergren J. The Charlson Comorbidity Index in Registry-based Research. Methods Inf Med 2017; 56: 401-406
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205-213
    CrossrefPubMedGoogle Scholar
  • 22 Thorlacius H, Uedo N, Toth E. Implementation of endoscopic submucosal dissection for early colorectal neoplasms in Sweden. Gastroenterol Res Pract 2013; 2013: 758202
    CrossrefPubMedGoogle Scholar
  • 23 Svensson M, Nilsson F. The Swedish Dental and Pharmaceutical Benefits Agency's willingness to pay for new drugs has been analyzed. Lakartidningen 2016; 113: DX44
    PubMedGoogle Scholar
  • 24 Morino M, Allaix ME, Arolfo S. et al. Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate. Surg Endosc 2013; 27: 3315-3321
    CrossrefPubMedGoogle Scholar
  • 25 Hahnloser D, Wolff BG, Larson DW. et al. Immediate radical resection after local excision of rectal cancer: an oncologic compromise?. Dis Colon Rectum 2005; 48: 429-437
    CrossrefPubMedGoogle Scholar
  • 26 Piessen G, Cabral C, Benoist S. et al. Previous transanal full-thickness excision increases the morbidity of radical resection for rectal cancer. Colorectal Dis 2012; 14: 445-452
    CrossrefPubMedGoogle Scholar
  • 27 Bulut O, Levic K, Hesselfeldt P. et al. The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study. Tech Coloproctol 2014; 18: 83-84
    CrossrefPubMedGoogle Scholar
  • 28 Dobson MW, Geisler D, Fazio V. et al. Minimally invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care. Colorectal Dis 2011; 13: 811-815
    CrossrefPubMedGoogle Scholar
  • 29 Fleshman J, Branda M, Sargent DJ. et al. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: The ACOSOG Z6051 Randomized Clinical Trial. JAMA 2015; 314: 1346-1355
    CrossrefPubMedGoogle Scholar
  • 30 Keller DS, Senagore AJ, Lawrence JK. et al. Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection. Surg Endosc 2014; 28: 212-221
    CrossrefPubMedGoogle Scholar
  • 31 Park EJ, Cho MS, Baek SJ. et al. Long-term oncologic outcomes of robotic low anterior resection for rectal cancer: a comparative study with laparoscopic surgery. Ann Surg 2015; 261: 129-137
    CrossrefPubMedGoogle Scholar
  • 32 Saito Y, Uraoka T, Yamaguchi Y. et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72: 1217-1225
    CrossrefPubMedGoogle Scholar
  • 33 Ronnow CFUN, Toth E, Thorlacius H. Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized Western center. Endosc Int Open 2018; 11: E1340-E1348
    PubMedGoogle Scholar
  • 34 Spychalski M, Skulimowski A, Dziki A. et al. Colorectal endoscopic submucosal dissection (ESD) in the West – when can satisfactory results be obtained? A single-operator learning curve analysis. Scand J Gastroenterol 2017; 52: 1442-1452
    CrossrefPubMedGoogle Scholar
  • 35 Saclarides TJ. Transanal endoscopic microsurgery. Clin Colon Rectal Surg 2015; 28: 165-175
    Article in Thieme ConnectPubMedGoogle Scholar