Economics of Squamous Cell Carcinoma of the Head and Neck
Jess Roberts, M.D.
February 7, 2008
Disclaimer: The information contained within the Grand Rounds Archive is intended for use by physicians and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No warranties, either express or implied, are made with respect to accuracy, completeness or timeliness of this material. This material does not necessarily reflect the current or past opinions of the faculty of Baylor College of Medicine and should not be used as a basis for diagnosis or treatment, and is not a substitute for professional consultation and/or peer-reviewed medical literature.
KA is a 59-year-old female who presented to Ben Taub with a 3-month history of left tongue pain. She denied oral bleeding, hemoptysis, dysphagia, weight loss, or voice changes. You can see her past medical history and current medicines she is taking. She did report about 60-pack-year smoking history and no significant alcohol intake. On physical exam, she had a 1cm non-indurated, white, left lateral tongue plaque. There was also a left level I, 2cm X 1cm lymph node that was palpable. The initial clinic biopsy showed invasive squamous cell carcinoma. We ordered a CT scan, which showed a soft tissue fullness in the left oropharynx extending into the left base of tone without any radiographically significant lymphadenopathy. She was preoperatively stages this T1N1M0. She subsequently underwent wide local excision of the left lateral tongue cancer with left levels I-III neck dissection. Pathology revealed infiltrating keratinizing squamous cell carcinoma, about 0.6cm, without lymphovascular or perineural invasion. Zero of 12 lymph nodes were positive. Postoperatively, she was staged as T1N0M0. Currently the patient shows no evidence of disease and is attending a smoking cessation class.
As far as the epidemiology of squamous cell carcinoma, the American Cancer Society estimates about 34,000 new cases of oral and pharyngeal cancer in 2007, with 7,550 deaths, and about 11,000 new cases of laryngeal cancer diagnosed each year. African-American males a higher incidence and mortality than any other racial/ethnic group. Squamous cell carcinomas are more prominent in the aging population and with increasing costs, it is becoming more of a problem.
Moving on to advances in treatment, there is induction chemotherapy. There have been some recent studies that have shown some indications that induction chemotherapy may be useful. Microsurgical and minimally invasive techniques are increasingly used. There is also increased use of imaging technology, along with accelerated radiotherapy and advances in radiotherapy planning and delivery. Despite these advances, survival rates in head and neck cancer have remained pretty much unchanged, and, with these advances in treatment, there are economic considerations - new and greater costs.
In looking at economic considerations, there are three different types of costs we will discuss. Direct costs include hospital services, physician fees, lab tests, diagnostic procedures and therapies. Indirect costs may be costs we do not think about all the time, but include resources that are lost: lost productivity, disability and premature death. These are also intangible costs, which are more psychosocial in nature.
Health economic research involved understanding the cost of an intervention in relation to the benefits derived from it. Over the past 30 years, health care spending has risen from about 6% to 14% of the gross domestic product. There are two main analytical approaches: cost minimization and cost effectiveness.
In cost effectiveness analysis, we use costs per additional quality adjusted life-year and measure treatment effectiveness. As far as the economic burden of squamous cell carcinoma, in 2004, Lang et al. analyzed the economic burden in a retrospective cohort study using data from the SEER and Medicare claims. Their study included about 4500 Medicare patient beneficieares, 65 years and older, who were diagnosed with head and neck cancer. The control group was a group of the same age with similar comorbidities. You can see that patients in the earlier stages were more likely to required single modality treatment, and as you can see from this table, those with more more local, regional and distant disease required multimodality treatments. This graph, summarizes the fact that the patients with SCCHN, compared with the matched control patients, had much higher hospital payments, about a $14,000 difference over the five years that the patients were followed, and that there was about a $25,000 difference in total medicare patients between the two groups. Most of the difference in the medical payment was incurred during the first year of follow-up, more than 85% of the total cost.
Patients diagnosed with advanced stage cancer used more resources and incurred more costs despite their shorter follow-up (from higher mortality). .The expected excess burden to Medicare for incident cases followed for five years ism ore than $250 million., and the annual excess costs attributable to SCCHN exceed the excess cost associated with breast, prostate, colon and rectal cancers. Lung and ovarian cancer have the highest annual costs.
As an example of the smoking related burden in association with head and neck cancer, Korea has one of the highest rates of male smoker in the world. The burden of smoking related had and neck cancer was less than lung cancer but higher than smoking-related kidney and urinary cancer. In this graph depicting the burden of head and neck cancers in Korea, we can see the years of life lost, both disability-adjusted life years and years of healthy life loss. These are indirect costs.
Most studies discuss direct costs, but indirect costs are illustrated by a study by Ruff et al. A study by the RAND Corporation estimated that a smoked, aged 20 years, will lose about 4.3 years of life, or about 7 minutes of life per cigarette. In diseases with high premature mortality, like head and neck cancer, smoking causes higher indirect costs. This graph illustrates the percentage of direct cost with for different types of diseases. Note that only 16% and 20% of the total direct costs result from oral cavity and laryngeal cancer, compared with, for example, people with atherosclerotic disease, which accounts for about 80% of the direct costs. In these other diseases, people tend to live longer with their disease, and require more treatments in comparison to the head and neck cancer patients.
So, the factor that would result in the most cost saving scenario would be the prevention of squamous cell carcinoma all together. As we know, it is mostly associated with tobacco use and excessive alcohol consumption. A 2003 study in the Netherlands used dynamic multistate modeling to analyze smoking prevention programs. Health gain in the short-term is higher with programs aimed at quitting smoking, since potential quitters have higher disease and mortality risks. However, long term results are greater in programs that aim at discouraging the population not to start smoking, as well as in programs that increase tobacco taxation, both of which are aimed at younger populations.
With these current smoking prevention programs, the incidence of lung cancer has fallen more rapidly than the incidence of oropharyngeal cancers, so alcohol consumption may be a more important causal factor. Alcohol consumption has been identified as a causal factor since the 1950s and, in combination with smoking, increases the risk of head and neck cancer by a factor of 15, in a linear correlation with amount and duration. And this graph shows the relative risk of cancer of the upper aerodigestive tract with alcohol consumption in never-smokers. Increased amounts of whiskey equivalents (combined intake of veer, wine and liquor), increases the relative risk of head and neck cancer in never-smokers. So, obviously alcohol is a significant factor in developing head and neck cancer.
So next, we will the relationship between costs and staging. Zavras et al. analyzed the cost differences between stages of oral cavity cancer. The cost per patient increases in each stage from Stage I to Stage IV. If we look at mean hospitalization days for each stage, we see that as the stages go up, there is more hospitalization, due primarily to the patients simply requiring more treatment, and he cost goes up as hospitalization costs go up. In this study, surgery was not associated with significant increased costs across the stages, but additional chemotherapy and radiation did cause a significant increase in costs as the stages went up.
Next we will consider diagnosis in relationship to continuity of care, use of PET in the staging of patients, and chest CT vs. CXR in staging. In 2004, more than 50% of oral cancers were diagnosed at advanced stages. So, in a 2006 study, Reid and Roxier analyzed continuity of care and earlier diagnosis of head and neck cancer. They found that regular care resulted in an earlier diagnosis when the provider was an internist and the location of the cancer was the oral cavity. When the provider was a family practitioner or when the cancer location was pharyngeal or laryngeal, there was no statistical significance in overall stage at diagnosis. So, earlier diagnosis often results in the ability to treat with a single modality, lower mortality, decreased medical expenditure and improvement in that patient’s quality of life.
Once early diagnosis has been made, one option can be further imaging prior to observation, surgery or radiotherapy. PET scans do show some progress in this area, and Hollenbeak et al have analyzed its cost effectiveness. The PET strategy was cost effective as long as the cost of providing the scan was below about $50,000. The authors suggest a cost-effective ratio of $8718 per year os life saved and $2505 per QALY. The PET aided diagnosis of occult, subclinical disease in HNSCC patients, which affects treatment outcome and long-term survival, since it can result in regional treatment failures. The PET scan is more expensive, but these authors felt that the additional expenditure may be considered worthwile in terms of value gains in QALYs.
Let us move on to chest x-ray and CT. The lung is the most common site of metastasis in head and neck cancer and two imaging modalities used for diagnosis are chest x-ray and CT. These are the results of study of stage III and IV head and neck cancer. You can see that there was only one false positive, and 1/25 had positive chest x-ray and positive CT. With the positive chest x-ray, we would go ahead and get a CT scan, so really, no patient in this study demonstrated benefit from the routine addition of CT to CXR in the initial screening. With the positive chest x-ray, we are going to get a CT scan to look at the lesions we see on chest x-ray. So, the additional cost of getting a CT scan first line is about $13,000 and, in this small study population, patients did not really benefit.
After diagnosis, we need to consider the treatment of head and neck cancer. We will go over different aspects of treatments and the cost associated with them. First we will talk about radiation. As I mentioned earlier, accelerated radiotherapy is one of the new technologies used in treating head and neck cancer and this is different from conventional radiotherapy, In accelerated radiotherapy, the chief side effects are greater initially, and patients were more likely be admitted for hospital for NG tube feeds, but for a less extended time period. This is the table comparing the costs of accelerated radiotherapy and conventional radiotherapy. You can see the cost was comparable across treatments and, at times, therapeutic responses have been greater in the accelerated radiotherapy.
Dinardo et al. evaluated the usefulness and resultant cost of frozen sections in head and neck cancer surgery. Their study included about 80 patients, and 420 frozen sections. The estimated charge per patient for the frozen sections was about $3143. The total cost was about $250,000. In this study, a negative frozen section did not necessarily ensure tumor-free margin on the final specimen, but a positive margin uniformly reflected a positive permanent margin. Twelve of the patients had positive frozen section. Six of these would have been candidates for re-operation based on the tumor extent and location. Re-operating costs were estimated to be $25,580, which subtracted from the total frozen cost means that the cost of frozen sections was now $224,000. So, their suggestions from this study are that frozen sections are best used in cases with the highest likelihood of successful margin revision, and that the surgeon should continue to operate while waiting for margin results. Frozen sections margins are most helpful in patients with early-stage disease and those undergoing re-resection.
Davis et al. performed a cost minimization analysis of total laryngectomy with post-op XRT vs. induction chemotherapy followed by XRT. The VA Laryngeal Cancer Study Group found no difference in survival and quality of life differences have been questionable when total laryngectomy is compared to organ preservation therapy. They used a cost minimization analysis, which is a technique to choose the technology when the outcomes are equivalent. This is a graph showing the range of costs of each of the variables. Only when the cost of chemotherapy was at its least expensive was organ preservation favored. This study indicates that costs can be considered when determining treatment decisions.
In a recent study, Kosuda et al. looked at the cost effectiveness of sentinel lymph node biopsy in the N0 neck in a study population of 11 patients. The prevalence of micrometastasss is about 30% in head and neck cancer. So far in the literature, the sensitivity and specificity of navigation surgery is about 90% and 100% respectively. This graph illustrates the cost savings associated with sentinel node navigation surgery vs. the ipsilateral neck dissection strategy. Only when the prevalence of micrometastases reached 85% is the cost effectiveness of neck dissection greater in the cost effectiveness of sentinel lymph node surgery. They estimated that the sentinel lymph node surgery would save about $1200 for N0 neck patients and avoid the morbidity associated with neck dissection.
Reconstructive follows cancer resection. There are a range of studies on the cost effectiveness of free vs. pedicled flap procedures. Most studies show significant difference between the costs of the reconstructive methods. Kroll et al found cost saving in free flap reconstruction when compared with pedicled flaps. In this study, the pedicled flap patients stayed in hospital on the average of longer and incurred about $12,000 more in hospital costs. The pedicled flaps were selected for patients with more advanced disease and with systemic medical issues, which may have contributed to longer hospitalizations and increased costs. Free flaps result in fewer complications and more rapid patient recovery. So, as in all the things we have discussed, we have to still think about the patients and what we will help their quality of life.
After diagnosis and treatment, we must look at follow-up of patients. Currently there is substantial variation in follow-up practices. There is little evidence supporting these practices, and these variations could result in unrestrained costs. There is little evidence to support the different practices, and variations in follow-up could result in unrestrained costs, which are unnoticed because of the lack of research in this area. Vingo et al analyzed these follow-up practices. They included 31 documented strategies, twelve of which were generic and 19 site specific. The most costly was 27 office visits. The cheapest follow-up strategy was with 8 office visits in 5 years. The range of charges between the generic strategies for patients was about $1200 versus $7500. Averaged over recurrences and/or second primary cancers detected during the 5-year follow-up, the estimated charge per detected recurrence and/or second primary cancer ranged from $2587 for the non-intensive follow-up to about $49,242 for the intensive follow-up. No one strategy has been documented as improving survival and quality of life. So, they recommend an approach based on the clinical presentation of the patient and not just a standard algorithm. Those follow-up strategies including more CTs and MRIs were obviously the more costly follow-up strategies. This study did not include indirect cost, but with more follow-up, more time is lost for the patient, the patient has to pay for transportation and, if the patient has children, more child care costs are also associated. There have been prospective, randomized controlled trials for breast cancer concerning post operative surveillance, and this would be a good idea for head and neck cancer.
One solution to cost is clinical care pathways, structure patients health care plans that organize daily interventions and goals for a specific diagnosis or procedure along a time line. This is a tool to decrease resource utilization. In 1996, the University of Pennsylvania implemented a clinical care pathway for patients undergoing a major resection. Their goal was to discharge the post laryngectomy patient on postoperative day #5 to #6, and a flap reconstruction patient on postoperative day #8. When implemented, these clinical care pathways decreased significantly the total length of stay, the ICU length of stay and the total non-ICU length of stay, all major costs associated with head and neck cancer. The readmission rate within 30 days did not change as they implemented the clinical care pathway. Here is the graph showing the decreased costs associated with the implementation of the clinical care pathway. No post-op complications increased significantly with the implementation of the clinical care pathways, but the incidence of post-op pneumonia did decrease significantly when they introduced these clinical care pathways.
So, healthcare costs among patients with cancer are dominated by hospitalization costs. Successful, expedient discharges depend on good communication among the multiple services required in the treatment of head and neck cancer, the family, as well as patient education and timely rehabilitation therapy.
A reduction in utilization of multimodality therapies is only possible if the patients are diagnosed earlier. Along with these direct cost savings come indirect savings: increased survival and increased quality of life. But, cost should not be the primary consideration. The highest priority is to achieve increased survival and maintain a good quality of life for that patient. But, since society has only limited resources, minimizing costs cannot completely be ignored.
KA is a 59-year-old female who presented to Ben Taub with a 3 month history of left tongue pain. She denied oral bleeding or hemoptysis. She reported a previous negative throat culture for yeast. She had no dysphagia or voice changes, but there was significant pain with chewing. Her past medical history was positive for hypertension and hyperlipidemia. Her past surgical history consisted of a hysterectomy. Her regular medicines were zocor, primarin, and aspirin, and she was allergic to tetracycline. Her social history was positive for 60 pack-year smoking history and no significant alcohol. Review of systems was negative for weight loss. Her physical exam was only positive for a left-lateral, ~1cm, non-indurated, white plaque and left, level II, 2x1 cm lymph node.
A biopsy was taken on presentation, it was positive for invasive squamous cell carcinoma. CT of the neck showed soft tissue fullness in the left oropharynx extending into the base of tongue. There were no radiographically significant lymph nodes. Preoperatively she was staged as T1N1M0.
The patient underwent wide local excision of the left lateral tongue cancer with left levels I – III neck dissection. Pathology results revealed infiltrating, keratinizing squamous cell carcinoma, 0.6 cm, without lymphovascular or perineural invasion with 0/12 lymph nodes positive for carcinoma. Post operatively staged as T1N0M0. Currently with no evidence of disease and attending a smoking cessation program at Ben Taub.
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