Management of the N0 neck in early stage oral squamous cell cancer: a modeling study of the cost-effectiveness

Abstract

Objectives: To assess the cost-effectiveness of five strategies for diagnosing and treating cT1-2N0 oral squamous cell cancer.

Materials and methods: A Markov decision analytic model was used to evaluate the cost-effectiveness of (1) elective neck dissection (END), (2) watchful waiting (WW), (3) gene expression profiling (GEP) followed by neck dissection (ND) or WW, (4) sentinel lymph node (SLN) procedure followed by ND or WW, and (5) GEP and SLN (for positive GEP) followed by ND or WW. Uncertainty was addressed using one-way and probabilistic sensitivity analyses.

Results: Base-case analysis showed that SLN procedure followed by ND or WW was the most effective and most cost effective strategy. Compared with direct END the incremental cost effectiveness ratio was €3356 per QALY gained. Uncertainty analysis showed that the model was sensitive to changes in assumed occult metastases incidence and utility values. SLN was found to have the highest probability (66%) of being cost-effective of the five strategies, at a willingness to pay of €80,000 per QALY.

Conclusions: Given the current evidence and costs the SLN procedure followed by ND or WW appears to be the most cost effective strategy for diagnosing and treating oral squamous cell cancer patients. Our model provides the foundation for future diagnostic and therapeutic research in this field and shows that further information on quality of life in this population is highly valuable.

Keywords: Cost effectiveness; Decision support techniques; Gene expression profiling; Head and neck Neoplasms; Markov Chains; Mouth Neoplasms; Neck dissection; Quality-adjusted life years; Sentinel lymph node biopsy.