Economic Analyses in Squamous Cell Carcinoma of the Head and Neck: A Review of the Literature From a Clinical Perspective

The purpose of this review was to describe cost-effectiveness and cost analysis studies across treatment modalities for squamous cell carcinoma of the head and neck (SCCHN), while placing their results in context of the current clinical practice. We performed a literature search in PubMed for English-language studies addressing economic analyses of treatment modalities for SCCHN published from January 2000 to March 2013. We also performed an additional search for related studies published by the National Institute for Health and Clinical Excellence in the United Kingdom. Identified articles were classified into 3 clinical approaches (organ preservation, radiation therapy modalities, and chemotherapy regimens) and into 2 types of economic studies (cost analysis and cost-effectiveness/cost-utility studies). All cost estimates were normalized to US dollars, year 2013 values. Our search yielded 23 articles: 13 related to organ preservation approaches, 5 to radiation therapy modalities, and 5 to chemotherapy regimens. In general, studies analyzed different questions and modalities, making it difficult to reach a conclusion. Even when restricted to comparisons of modalities within the same clinical approach, studies often yielded conflicting findings. The heterogeneity across economic studies of SCCHN should be carefully understood in light of the modeling assumptions and limitations of each study and placed in context with relevant settings of clinical practices and study perspectives. Furthermore, the scarcity of comparative effectiveness and quality-of-life data poses unique challenges for conducting economic analyses for a resource-intensive disease, such as SCCHN, that requires a multimodal care. Future research is needed to better understand how to compare the costs and cost-effectiveness of different modalities for SCCHN.

Introduction

Evidence of a new treatment's safety and efficacy is no longer sufficient to justify reimbursement in many countries, because economic evidence is becoming increasingly important in the coverage decisions regarding novel therapies. When clinical data indicate a small or even questionable effect at a high level of expenditure, economic data are at times given high priority. Squamous cell carcinoma of the head and neck (SCCHN), with its intense multimodality treatment approach combined with acute and long-term sequelae, is a prime example of a resource-intensive disease for which the economic data should be interpreted in context with the clinical evidence.

Squamous cell carcinoma of the head and neck accounted for approximately 3% (approximately 50,000) of all new cancer cases and 2% (approximately 12,000) of all cancer deaths in 2010 in the United States (1). Most patients with SCCHN present with locally advanced and curable disease, and the vast majority of these patients receive aggressive multimodality treatments that include surgery, radiation therapy, and chemotherapy with curative intent. In general, curative surgical resection is the recommended treatment for patients with early-stage disease without functional morbidity. Single-modality external beam radiation therapy (RT) may be an alternative for early-stage cases when functional concerns preclude surgical resection. For patients with locally advanced disease a multimodal approach is often the preferred course of action, with surgical resection followed by adjuvant RT or concurrent chemoradiation therapy (CRT) to decrease the risk of recurrence. An organ-preservation approach with up-front CRT may also be appropriate (2). Induction or neoadjuvant chemotherapy has also been proposed, with the aim of decreasing the risk of distant failure resulting from micrometastatic disease, although studies exploring this treatment modality have shown conflicting findings 3, 4, 5. Nevertheless, in the locally advanced setting, the multidisciplinary approach involving surgery, RT, and chemotherapy has been successful in achieving >70% survival at 2-year follow-up (6). In the metastatic or recurrent setting, the management strategy typically involves systemic chemotherapy. However, survival is poor regardless of the regimen of choice. In addition to its resource-intensive nature, there has been a change in the demographics of those afflicted with SCCHN, with a shift from older patients being diagnosed with tobacco-related disease to young patients whose cancers are related to human papillomavirus infection, bringing SCCHN treatment modalities and their costs to the forefront of the discussion. This review aims to evaluate the current literature related to economic analyses of treatment modalities for SCCHN and to place the economic evidence in the context of clinical practice. Further, to understand discrepant study results, we also aim to explore some assumptions underlying these analyses.