OBJECTIVES: Adjuvant chemotherapy is not recommended for patients with average-risk stage II (T3N0) colon cancer. Nevertheless, a subgroup of these patients who are CDX2-negative might benefit from adjuvant chemotherapy. We evaluated the cost-effectiveness of testing for the absence of CDX2 expression followed by adjuvant chemotherapy (fluorouracil combined with oxaliplatin [FOLFOX]) for patients with stage II colon cancer.
METHODS: We developed a decision model to simulate a hypothetical cohort of 65-year-old patients with average-risk stage II colon cancer with 7.2% of these patients being CDX2-negative under 2 different interventions: (1) test for the absence of CDX2 expression followed by adjuvant chemotherapy for CDX2-negative patients and (2) no CDX2 testing and no adjuvant chemotherapy for any patient. We derived disease progression parameters, adjuvant chemotherapy effectiveness and utilities from published analyses, and cancer care costs from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Sensitivity analyses were conducted.
RESULTS: Testing for CDX2 followed by FOLFOX for CDX2-negative patients had an incremental cost-effectiveness ratio of $5500/quality-adjusted life-years (QALYs) compared with no CDX2 testing and no FOLFOX (6.874 vs 6.838 discounted QALYs and $89 991 vs $89 797 discounted US dollar lifetime costs). In sensitivity analyses, considering a cost-effectiveness threshold of $100 000/QALY, testing for CDX2 followed by FOLFOX on CDX2-negative patients remains cost-effective for hazard ratios of <0.975 of the effectiveness of FOLFOX in CDX2-negative patients in reducing the rate of developing a metastatic recurrence.
CONCLUSIONS: Testing tumors of patients with stage II colon cancer for CDX2 and administration of adjuvant treatment to the subgroup found CDX2-negative is a cost-effective and high-value management strategy across a broad range of plausible assumptions.
Bibliographical noteFunding Information:
Conflict of Interest Disclosures: Dr Schrag reported receiving grants from Pfizer and GRAIL and personal fees from JAMA outside of the submitted work. No other disclosures were reported. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding/Support: This work was supported by a grant from Fulbright and the National Council of Science and Technology of Mexico and a Doctoral Dissertation Fellowship from the Graduate School of the University of Minnesota as part of Dr Alarid-Escudero’s doctoral program. Drs Kuntz and Alarid-Escudero were supported by 2 grants from the National Cancer Institute at the National Institutes of Health (grant numbers U01-CA-199335 and U01-CA-253913) as part of the Cancer Intervention and Surveillance Modeling Network. No other funding was noted.
© 2021 ISPOR–The Professional Society for Health Economics and Outcomes Research
- cost-effectiveness analysis
- decision-analytic model
- immunohistochemistry testing
- stage II colon cancer
PubMed: MeSH publication types
- Research Support, Non-U.S. Gov't
- Journal Article
- Research Support, N.I.H., Extramural