- 學位論文
台灣地區口腔癌病患術後定期接受上消化道內視鏡篩檢食道癌之成本效益-以馬可夫決策模型進行分析
The cost-effectiveness of routine esophageal cancer screening by endoscope for oral cancer patients in Taiwan: a Markov decision analysis approach
摘要
研究背景:口腔癌發生個案數近年有增加趨勢，在台灣地區2009年男性癌症發生率排名第四，死亡率也是排名第四，病人死亡年齡中位數55歲，比起肺癌造成之死亡年齡中位數提早了十年以上。目前口腔癌病人治療成效良好，第一期病人五年存活率75%,第二期病人五年存活率65.6%,第三期病人五年存活率49%,第四期病人五年存活率30%。雖然口腔癌治療成果改善，但是因為口腔癌病人本身在呼吸道及消化道暴露致癌因子的緣故，罹患第二癌之風險遠高於一般族群，部分病人是死於第二癌而非口腔癌。根據嘉義長庚醫院利用台灣癌登資料庫所做的研究顯示，口腔癌病患罹患之第二癌以食道癌最為顯著增加。然而，在口腔癌病人術後之追蹤項目，上消化道內視鏡篩檢食道癌並非常規例行性檢查，病人通常是在發生吞嚥困難症狀時才接受上消化道內視鏡檢查。在此情況下，食道癌被診斷時通常為較晚期之食道癌，治療結果不佳。 研究目的:本研究探討將上消化道內視鏡檢查列入口腔癌接受根除性治療後之病人術後常規檢查項目，是否能因早期發現食道癌，降低食道癌相關之死亡，改善口腔癌病人之長期存活率。同時探討此政策之耗用資源與效益，是否值得將上消化道內視鏡檢查列入口腔癌病人術後常規檢查。 研究方法:本研究以「馬可夫決策模型」(Markov decision model)進行世代模擬分析(Markov cohort simulation)，評估介入策略的經濟效益。介入策略將上消化道內視鏡列為口腔癌病人治療追蹤過程之常規執行項目，探討是否能改善病人之長期存活率及健康狀況，以及該項治療策略所耗用之資源及效益。模擬研究對象為台灣地區口腔癌病人，於初次治療後達到治療後達到「口腔癌緩解」狀態，共1000名男性，其年齡為50歲。每一個週期設定為半年，追蹤10年或至病人死亡為止。對照組為依照目前口腔癌臨床指引每半年接受追蹤檢查。檢查項目並不包括例行性上消化道內視鏡檢查，僅在病人臨床症狀有吞嚥困難時才安排上消化道內視鏡檢查。在口腔癌緩解狀態滿五年後，視為治癒，不再執行例行性追蹤。而實驗組(A)除依照目前臨床指引追蹤外，前五年每半年一次同時接受放大窄頻光源上消化道內視鏡檢查(magnified narrow-band imaging endoscope)至滿五年。實驗組(B)除依照目前臨床指引追蹤外，前五年每一年一次同時接受放大窄頻光源上消化道內視鏡檢查至滿五年。五年之後追蹤方式與對照組相同。當發現口腔癌復發時或發現食道癌時，三組之處理方式相同。經過10年後，比較三組病人存活狀況，包括癌症相關死亡人數、及品質調整生命年數(QALY: quality-adjusted life year)。同時將針對實驗組耗用費用及增加之生存人年，進行成本效益分析，計算每增加一個品質調整生命年數需耗用多少費用(ICER: incremental cost-effectiveness ratio)。參考本國2012年GDP:20336美元，本實驗設定之閾值為新台幣600000/ QALY。 結果:經過10年追蹤後，實驗組(A)存活人數為534人，實驗組(B)存活人數為534人，對照組存活人數為515人。口腔癌相關之死亡，實驗組(A)為327人，實驗組(B)為327人，而對照組為325人。食道癌相關之死亡人數，實驗組(A)為19人，實驗組(B)為20人，而對照組為44人，食道癌相關之死亡人數減少50%以上。在計算品質調整生命年數及耗用費用後，此介入行為實驗組(A)之ICER 值為新台幣198617元/QALY，實驗組(B)實驗組之ICER 值為新台幣148665元/QALY，均低於閾值。 結論:針對口腔癌接受根除性治療後之病人，將上消化道內視鏡檢查列入口腔癌病人術後常規檢查，能因早期發現食道癌降低食道癌之死亡，改善病人之長期存活率。與現行臨床指引相比較，具有經濟效益。
並列摘要
Background: The incidence of oral cancer in Taiwan has increased in the past decade. Oral cancer is the 4th leading cause of cancer deaths for males. The median age of death is 55-years of age, at least 10 years younger than those with lung cancer. Treatment and prognosis of oral cancer remain favorable. Patients with stages one through to four have a 5-year survival rate of 75%, 65.5% , 49% and 30% respectively. Although the results of treatment have improved, however, since most of the patients were exposed to the carcinogens such as alcohol, smoking and betel quid, they have a higher incidence of developing secondary cancers. According to the Taiwan Cancer Registry, the most common one being cancer of the esophagus. Between 10- 20 % of patients with oral cancer develop squamous cell carcinoma of the esophagus synchronously or metachronously. Since esophagogastroduodenoscopic (EGD) screening for esophageal cancer is not routinely performed for the follow-up of patients with oral cancer, the diagnosis is usually made only after the symptom of dysphagia occurred. This results in the late diagnosis and consequent poorer prognosis for these patients. Purpose: The objective of the study is to evaluate the effect and cost-effectiveness of including endoscopic screening of esophageal cancer for patients who received curative treatment for their oral cancer. The authors shall assess whether early detection of esophageal cancer lowers its mortality, and thus improves overall survival rate of oral cancer. Methods: We developed a Markov decision model, in which Markov cohort simulation was used to assess the economic value of this intervention. In this model, 1000 patients with oral cancer aged 50 years of age were enrolled. All patients completed curative treatment and were at the state of remission. In the control group, all patients received postoperative surveillance every 6 months, according to national guidelines, until 60 years of age, or until they die. Esophagogastroduodenoscopy was arranged only when symptoms occur. In the experimental group, 2 different interventional strategies were used. This included screening by EGD (magnified narrow-band imaging endoscope) for esophageal cancer. In group A, EGD was performed every 6 months, and in group B, EGD was performed every year. The primary outcome was the survival difference, difference of quality-adjusted life year (QALY) gained, and incremental cost-effectiveness ratio (ICER). The threshold used to determine the cost-effectiveness was $20336 per QALY. One way sensitivity analysis is done for the important parameters. Results: The number of survivors after 10 years of follow-up was 515 in the control group, and 534 in both experimental groups A (screening every 6 months) and B (screening every year). The number of esophageal cancer related deaths was highest (44) in the control group, 19 in group A, and 20 in group B. respectively. The esophageal cancer related death decreased more than 50% in both EGD screening groups. The mean cost was ($18447, $18885, $18770) respectively. The ICER is $6620 per QALY for the group B, and $4955 per QALY for the group C. Both follow-up strategies were dominant as compared to current strategy. Conclusions: Routine esophagogastroduodenoscopy screening of esophageal cancer in addition to the current postoperative surveillance among patients with oral cancer seem to improve overall survival and is cost-effective.
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