In an era of health reform: Defining cost differences in current esophageal cancer management strategies and assessing the cost of complications

Objective: Outcomes assessing various treatment modalities for esophageal cancer primarily report results in terms of morbidity, mortality, survival, and quality of life. The most appropriate stage-by-stage treatment for esophageal cancer remains controversial. There are limited data outlining the comparative costs of surgical, combined modality and definitive chemoradiation treatments, and added costs associated with complications. Methods: Between 2000 and 2004, 4 treatment groups were studied: surgery alone, chemotherapy followed by surgery, chemoradiotherapy followed by surgery, and chemoradiotherapy alone. Fifteen consecutive patients from each group receiving their entire treatment at Virginia Mason Medical Center were identified. Patient demographics and outcomes were taken from a prospective institutional review board-approved surgical database, and chart review obtained information for neoadjuvant therapy and definitive chemoradiotherapy groups. Treatment-related costs were extracted from Virginia Mason Medical Center's financial data management system between date of diagnosis to 90 days after completion of primary therapy. Results: Treatment groups were similar in age, gender ratio, American Society of Anesthesiologists status, body mass index, and tumor cell type. Costs increased with the number of treatment modalities: surgery alone, $33,517; chemotherapy followed by surgery, $41,875; chemoradiotherapy followed by surgery, $47,389; and chemoradiotherapy alone, $46,659. Treatment-related complications were surgery alone, 47%; chemotherapy followed by surgery, 64%; chemoradiotherapy followed by surgery, 66%; and chemoradiotherapy alone, 87% (P = .139). Complications increased costs in all groups: surgery alone, 26% (P = .008); chemotherapy followed by surgery, 23% (P = .001); chemoradiotherapy followed by surgery, 9% (P = .702); and chemoradiotherapy alone, 19% (P = .248). Conclusions: Costs vary significantly among treatment approaches: surgery alone costs 80% of chemotherapy and surgery, 71% of chemoradiotherapy and surgery, and 72% of chemoradiotherapy alone. Costs of tri-modality therapy and definitive chemoradiotherapy are similar. Especially in the absence of definitive evidence-based data, these costs should be a factor in the production of future national treatment guidelines. Decreasing costs requires future quality initiatives in esophageal cancer treatment that focus on minimizing complications related to treatment. (J Thorac Cardiovasc Surg 2011;141:16-21)