Cost-effectiveness analysis of radiotherapy versus surgery for esophageal squamous cell carcinoma in China: a Markov model study based on real-world data

Studies on cost-effectiveness analysis of esophageal cancer are relatively common. However, there are few cost-effectiveness analyses that take a comparative approach between radiotherapy and surgery for esophageal squamous cell carcinoma (ESCC). A cost-effectiveness Markov model was constructed to explore the relationship between the benefits and costs of radiotherapy versus surgery for ESCC in China. According to the observational data (patients’ medical records), 196 patients with ESCC enrolled for data were classified into surgery and radiotherapy two groups, both groups received preoperative and postoperative chemoimmunotherapy. A Markov model was constructed using TreeAge Pro Healthcare software to simulate the diseases progression after treatment. The model cost parameters were derived from the average treatment expenditures by real-world patients. The survival formula, fitted to real-world patient data in R, was used to calculate model transition probabilities.​ The utility value parameters were obtained by reviewing literature. Base-case, one-way deterministic sensitivity, and probabilistic sensitivity analyses were performed. The results were evaluated against willingness-to-pay (WTP) thresholds to determine the cost-effectiveness of treatments. Among 196 patients (131 males; 114 surgery group), median overall survival was 41.3 vs. 30.4 months and progression-free survival 28.0 vs. 20.6 months for surgery versus radiotherapy groups.​ Compared to radiotherapy, surgery had an incremental cost of 411,574.32 US dollars (USD), an incremental utility of 11.85 quality-adjusted life years (QALYs), and an incremental cost-effectiveness ratio of 34,744.52 USD/QALY, reaching 90% of the upper bound of WTP (three times the gross domestic product [GDP] per capita in China). One-way deterministic sensitivity analysis revealed that the costs of adverse event management and immunotherapy were key drivers affecting the incremental cost-effectiveness ratio. In probabilistic sensitivity analysis, at a WTP of 12,741.11 USD/QALY and 38,223.34 USD/QALY (1 to 3 times China’s per capita GDP), the probability of surgery being cost-effective was 10.1% and 62.5%, respectively. At a WTP of 33,080.09 USD/QALY, the probability was equal. In China, Surgery was marginally cost-effective compared to radiotherapy for ESCC.​​ WTP thresholds, adverse reactions costs and immunotherapy costs constituted the primary factors influencing health economic evaluation outcomes in ESCC surgery versus radiotherapy.