Cost-effectiveness of doing CEA-Scan studies

To fairly evaluate the cost of doing — or not doing preoperative CEA-Scan studies — it’s useful to note the economic as well as clinical consequences when metastatic disease is missed, and a patient is incorrectly judged cured by a primary procedure…and enters this monitoring and management pathway.

Audisio and colleagues¹² at the University of Milan reported on 505 patients who survived curative surgery for stage I-III colorectal adenocarcinoma, and then were closely followed for at least 4 years. Their monitoring technique mirrors that which is routinely used in the U.S., and the incidence of recurrence (141 of 505 – 28%) reflects recurrence rates in the U.S. They converted their costs to U.S. dollars – a conversion that may understate the actual costs of diagnostics and surgery in America’s medicolegal environment, but is useful at least as a relative guide to economic impact.

• The 141 patients with recurrence had a mean survival of 44.4 months.
• 109 of the 141 were judged likely to benefit only from a second operation of palliative intent (mean survival: 37.1 months). 32 of the 109 underwent one or more surgical procedures for cure. Eighteen were considered cured by those second operations (average 81.4 months survival).
• The investigators calculated the overall follow-up cost of these recurrent patients – originally judged "cured" – as
• $1,914,900 for following the 505 patients for 4 years ($3792 per patient, or $947/patient/year)
• $13,580 for each recurrence treated
• $59,841 for each case treated for cure
• $136,779 for each treated recurrent case actually cured

Thus, failure to properly identify patients with resectable metastatic disease during the preoperative workup increases the likelihood that

• Metastatic disease may not be fully discovered and resected during the primary or early second-look procedure.
• Patients not resectable for cure may receive unnecessarily radical procedures that increase their risk of complications, and the hospital and health plan to greatly increased costs.
• Patients who might benefit from adjuvant chemotherapy may be misstaged, and denied care that can delay and/or reduce the degree of recurrent disease.
• Rather than resecting preoperatively identifiable (by CEA-Scan) disease, the surgeon may inadvertently leave disease behind – disease that, upon later recurrence, will demand aggressive, expensive additional cost and risk.