Out of proportion.

Some say the added time and expense of long-course chemoradiation prior to resection of locally-advanced rectal cancer is out of proportion to its touted benefits. The main benefit being more conversions from an abdominoperineal resection (APR) to a sphincter-preserving low anterior resection LAR (39%) than seen with short-course radiation alone (19%). This cost-effectiveness analysis built simulation models using defined probabilities of outcomes generated from published data. Each strategy was tagged with chances as above for APR versus LAR when used on low-lying tumors and equal chances for local and/or distant recurrence and for late toxicity when used on any tumor. Various outcomes were then given a price point based on published Medicare fees. When run 1 million times across all locally-advanced tumors, long-course radiation afforded one additional quality (i.e., colostomy-free) adjusted life year (QALY) at the cost of roughly $133K. When run among low-lying tumors, this price dropped to just over $61K. TBL: For locally-advanced rectal tumors that are upfront candidates for LAR, short-course pre-op radiation alone gives you the most functional rectum for your buck. | Raldow, JAMA Netw Open 2019