Minimally-invasive hysterectomy versus open radical hysterectomy in early-stage cervical cancer: a cost-effective analysis of the LACC trial

Objectives: To determine the cost-effectiveness of minimally-invasive hysterectomy versus open radical hysterectomy in patients with early-stage cervical cancer. Methods: We created a model to evaluate the cost-effectiveness of minimally-invasive radical hysterectomy compared to open radical hysterectomy in women with newly diagnosed stage 1A1 (with lymphovascular invasion) thru IB2 (FIGO 2018) cervical cancer. We included 6,000 patients in the model which approached cost from a societal perspective. Surgical costs were calculated using the average Medicare reimbursement for the procedures with and without associated complications. Lost wages were calculated using return to normal daily activity per surgical approach and information from the Bureau of Labor Statistics. Estimated complication rates were calculated using the LACC trial data. Effectiveness was calculated as disease-free survival (DFS) at 4.5 years. We calculated incremental cost-effectiveness ratios (ICERs) to determine the cost per 4.5 year survivor. Univariate sensitivity analyses were performed. The willingness to pay threshold was $100,000 per year of DFS. Results: In the minimally-invasive radical hysterectomy cohort, the cost was $87.4 million (M) and yielded 5,160 4.5 year survivors. Comparatively, open radical hysterectomy cost $108.1 M and resulted in 5,760 4.5 year survivors. The ICER for open radical hysterectomy compared to minimally-invasive radical hysterectomy was $32,824 which fell well below our predetermined willingness to pay threshold of $450,000 per 4.5 year survivor. Sensitivity analyses were performed to determine the effect of complication rates on the model. The baseline rate of major complications with open radical hysterectomy was similar to minimally invasive radical hysterectomy (18.0 vs 16.0%). In order to evaluate the impact of medically compromised patients (comorbidities, obesity, and age >65), we varied the complication rates from 10-80% in the sensitivity analysis. With increasing complication rates in the open radical hysterectomy cohort, both the total costs and ICER increases ($64,044) but remains below the willingness to pay threshold. Conclusions: For patients with early-stage cervical cancer, open radical hysterectomy is cost-effective relative to minimally-invasive hysterectomy. Medical comorbidities and complication rates do not impact the results of the model. Open radical hysterectomy appears to be the preferred surgical approach for all patients with early-stage cervical cancer.