Effectiveness and cost-effectiveness of peri-operative versus post-operative chemotherapy for resectable colorectal liver metastases

Background: The role of neo-adjuvant chemotherapy prior to hepatectomy in patients with resectable colorectal liver metastases is currently a matter of debate. The aim of the present study was to analyse life-expectancy, quality adjusted life-expectancy and cost-effectiveness of the two chemotherapeutic strategies. Methods: A Markov decision model was developed, on the basis of parameters derived from an extensive literature search of the last ten years, to compare outcomes of pert-operative versus post-operative chemotherapy. Results: Life-expectancy observed for pert-operative chemotherapy was 54.56 months and 52.62 months with post-operative chemotherapy only; the quality-adjusted life-expectancy with pert-operative chemotherapy was 39.33 quality-adjusted life-months (QALMs) and 37.84 QALMs with post-operative chemotherapy. Pen-operative chemotherapy results in an increase in total costs of 1180 (sic) over ten years and in an incremental cost-effectiveness ratio (ICER) of 791.9 (sic)/QALM. The model was more sensitive to the expected 3-year recurrence-free survival (RFS) and cost of hepatic resection: with respect to an expected 3-year RFS <= 25% the pert-operative approach was more cost-effective than post-operative strategy but differences in average cost-effectiveness were small. The relationship between ICER and cost of hepatic resection was inverse because the higher the cost of hepatic resection, the higher the cost saving due to patients becoming unresectable during neo-adjuvant therapy. Conclusions: In the treatment of resectable colorectal liver metastases, the addition of neo-adjuvant chemotherapy could be cost-effective because it makes it possible to avoid hepatic resection in patients who do not respond to the neo-adjuvant approach; however, the life-expectancy of the two strategies is very similar. (C) 2011 Elsevier Ltd. All rights reserved.