What treatment for early-stage glottic carcinoma among adult patients: CO2 endolaryngeal laser excision versus standard fractionated external beam radiation is superior in terms of cost utility?

Abstract

To determine which treatment for Tis/T1 glottic carcinoma among adult patients, transoral CO(2) laser excision (TOL) versus external beam radiation (XRT), is superior in terms of cost utility. Cost-utility analysis. Six head-to-head comparison studies and 22 consecutive case series were identified to examine oncologic control. The case series were pooled as a composite group. Primary end points were local control (LC), laryngectomy-free survival (LFS), and overall survival (OS). Objective and subjective voice-quality measures were secondary end points. Third-party payer perspective was adopted for cost-utility analysis. Operational and capital costs were determined with the microcosting method. Rollback calculations and quality adjusted life years (QALYs) were calculated with decision-tree modeling. There were no significant differences between TOL surgery and XRT with respect to LC (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.51-1.3) and LFS (OR, 0.84, 95% CI, 0.42-1.66). The weighted mean difference for OS was 0.03. There were no objective differences for measures of voice quality. Decision-tree analysis was undertaken using mean 5-year local control initial probabilities. CO(2) laser cost $2475.65/case (US $2407.32/case), generating 1.663 QALYs, whereas radiation cost $4965.85/case (US $4828.79/case), generating 1.506 QALYs. This contrasts initial upstream costs for CO(2) laser (∼$1889/case, ∼US $1836.86/case) and radiation (∼$2454.70/case, ∼US $2386.95/case). This meta-analysis shows that there is no clear difference in oncologic outcome between TOL surgery and XRT. There is a trend for improved post-treatment voice quality with XRT, although the clinical significance of this is questionable. TOL surgery dominates XRT from a cost-utility standpoint primarily because of the enhanced downstream affordability of salvage treatment.