University of Twente Student Theses


Cost-effectiveness of neck treatment strategies for sentinel node-positive oral cavity squamous cell cancer : a microsimulation study

Koeken, V. (2023) Cost-effectiveness of neck treatment strategies for sentinel node-positive oral cavity squamous cell cancer : a microsimulation study.

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Abstract:Background: This study aimed to evaluate the cost-effectiveness of neck treatment strategies for cT1-2 SN+ oral cavity squamous cell cancer. The research investigated the routine application of neck dissection, neck dissection with postoperative radiotherapy, radiotherapy, or watchful waiting to improve clinical decision-making and patient management and enhance health outcomes, given the available data. The most important uncertainty in data that influences the outcomes were assessed. Methods: A microsimulation model was constructed to simulate primary and adjuvant neck treatment, regional disease recurrence, and salvage therapy in patients with T1/T2 sentinel node-positive oral cavity squamous cell carcinoma. This decision-analytic model was developed to study the costeffectiveness of neck treatment strategies for isolated tumour cells, micrometastasis and macrometastasispositive sentinel nodes separately. Survival, quality of life and costs associated with neck dissection, radiotherapy and observation were evaluated in these patient groups. Since individual patient data was not sufficiently available, literature was analysed, and clinical expertise was used to define input parameter values. A distribution was defined for each input parameter, describing the variation at the patient level. Uncertainty was addressed using deterministic and probabilistic sensitivity analyses. Value of information analyses described the value of additional research. Results: Simulating patients’ cost-effectiveness outcomes, it was estimated that radiotherapy I-V would give the highest number of QALY for the different dimensions of metastatic lymph node deposits in ITC, MiM and MaM size. In terms of cost-effectiveness, watchful waiting was the best treatment strategy for isolated tumour cells and micrometastasis and neck dissection I-III for macrometastasis. However, the PSA indicated a high degree of uncertainty in the cost-effectiveness of each strategy, with a probability of acceptable cost-effectiveness of 92%, 57%, and 58% given the Dutch threshold of €20,000/QALY. Uncertainty in the parameters non-SN metastasis (additional non-SN metastases after removal of the sentinel nodes) and in surgery field recurrence (recurrence in a neck level in which the nodes were dissected) had the most influence on the outcomes for isolated tumour cells and the micrometastasis model. For macrometastasis, uncertainty in the probability of non-SN in level IV and the probability of shoulder morbidity complications had the most influence on outcomes. Conclusion: The quality and quantity of available observational and literature data resulted in a large uncertainty surrounding the parameter values used for simulation modelling, and therewith the outcomes. Therefore, no clear conclusion can be drawn. Gathering more data to reduce uncertainty and make informed decisions is essential. The study should increase awareness of the importance of data collection of sentinel node-positive OSCC patients and influence key choices in data sharing.
Item Type:Essay (Master)
Radboudumc, Nijmegen, The Netherlands
Faculty:BMS: Behavioural, Management and Social Sciences
Programme:Industrial Engineering and Management MSc (60029)
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