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Cost-effectiveness analysis of margin-controlled surgery for vulvar Paget's disease
Kelly H Bruce1, James P Moriarty2, Bijan J Borah2
1Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.
Gynecologic Oncology Reports
|March 4, 2024
Summary
Mohs micrographic surgery excision (MMS-E) is more cost-effective for vulvar Paget's disease than wide local excision (WLE), despite higher initial costs. MMS-E offers more disease-free years, making it a favorable treatment option.
Area of Science:
- Gynecologic Oncology
- Surgical Cost-Effectiveness Analysis
- Paget's Disease of the Vulva
Background:
- Vulvar Paget's disease (VPD) is a rare intraepithelial malignancy requiring effective and economically viable treatment strategies.
- Traditional wide local excision (WLE) for VPD has been associated with significant recurrence rates.
- Mohs micrographic surgery excision (MMS-E) offers a precise surgical approach with potentially lower recurrence rates.
Purpose of the Study:
- To compare the cost-effectiveness of MMS-E versus WLE for treating vulvar Paget's disease.
- To model long-term costs and outcomes, including disease recurrence and reoperation rates.
- To evaluate treatment strategies based on disease-free years and quality-adjusted life years (QALYs).
Main Methods:
- A retrospective analysis of billing data for 24 patients undergoing MMS-E and 64 patients undergoing WLE for VPD.
- Standardized costs were calculated using Medicare reimbursements (2022 USD), incorporating physician and facility fees.
- A 10-year Markov model simulated treatment pathways, using institutional recurrence rates (MMS-E: 6.7% vs. WLE: 34.1% at 3 years) and a willingness-to-pay threshold of $100,000 per QALY.
Main Results:
- The initial cost per surgical episode was higher for MMS-E ($34,664) compared to WLE ($14,969).
- MMS-E demonstrated a lower incremental cost of $12,789 per disease-free year gained, attributed to reduced recurrence.
- The incremental cost per QALY gained for MMS-E was $72,820.
Conclusions:
- Mohs micrographic surgery excision (MMS-E) represents a cost-effective treatment for vulvar Paget's disease compared to the historical standard of wide local excision (WLE).
- The improved cost-effectiveness of MMS-E is primarily driven by its significantly lower recurrence rates.
- Further research incorporating health utility values is recommended to refine the cost-effectiveness analysis for this rare condition.
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