Economic Evaluation of Total Neoadjuvant Therapy and Watch and Wait in Rectal Cancer
Date
2025
Authors
Murshed, Ishraq
Editors
Advisors
Sammour, Tarik
Thomas, Michelle
Thomas, Michelle
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Thesis
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Abstract
Colorectal cancer remains one of Australia’s most prevalent cancers, ranking fourth in diagnosis in 2024. Managing rectal cancer is particularly challenging and expensive due to need for multi-disciplinary co-ordination and multi-modal treatments such as radiotherapy, chemotherapy, and surgery. Despite these treatments and often very morbid surgeries, traditional management still results in high rates of distant metastasis, which directly impacts patient survival prospects and quality of life (QoL), and drives up the costs of healthcare delivery, especially during palliative care phase. In 2023, Australia spent nearly $20 billion AUD on cancer – the highest healthcare expenditure by condition – more than doubling over the past decade whilst also causing the highest in healthcare burden. Rectal cancer treatment is almost 20% more expensive than colon cancer treatment, contributing substantially to this burden. Emerging management strategies, such as Total Neoadjuvant Therapy (TNT) and ‘Watch and Wait’ (W&W), offer promising clinical outcomes, including improved disease-free survival, increased rates of organ preservation, and enhanced QoL. While clinical effectiveness studies are well-documented, the cost-effectiveness of these strategies remain underexplored. Given the already burgeoning and finite healthcare resources, robust economic evaluations (EEs) are critical for integrating novel treatments into clinical practice. This thesis addresses this knowledge gap through four chapters. An initial literature review covers traditional rectal cancer management, novel strategies, and health EEs. The subsequent chapter feature a systematic review of healthcare EEs on W&W, analysing 12 studies from 8 different countries and healthcare systems between 2016 and 2024. Despite varying methodological details and quality, all studies found W&W to be dominant over traditional management, offering higher patient QoL whilst reducing healthcare costs. Only one study incorporated TNT, underscoring the need for updated EEs combining contemporary management strategies such as TNT and W&W. Following this, a comprehensive cost analysis of TNT within the Australian healthcare system was conducted, comparing TNT with selective W&W to standard management. This multi-institutional, trial-based cohort study and economic evaluation included 115 patients from 2014 to 2023 and provided real-world third-party payer healthcare costs over a 2-year time frame. Results demonstrated that TNT reduced costs a mean of $13,356.70 AUD per patient (9.51% lower). Finally, to evaluate broader implications of TNT and W&W adoption on the whole Australian healthcare system, a bi-national registry-based cohort study incorporating data from the Australian and New Zealand Bowel Cancer Outcome Registry was performed. Among 3,000 patients from 2018 to 2023, TNT utilisation increased significantly from 11% in 2018 to 41% in 2023, correlating with a decline in traditional neoadjuvant therapies. Extrapolating from the costing analysis, this shift resulted in nearly $10 million AUD in savings for the healthcare system. With TNT adoption likely accelerating, these cost savings are expected to grow substantially in the future. This thesis offers significant and novel contributions to the field of health economic evaluation in contemporary rectal cancer management. It provides compelling economic evidence supporting the incorporation of TNT & W&W into Australian rectal cancer clinical management guidelines. These novel strategies not only improve patient outcomes but also reduce nationwide healthcare expenditure, offering a more sustainable path forward for rectal cancer care.
School/Discipline
Adelaide Medical School
Dissertation Note
Thesis (MPhil.) -- University of Adelaide, Adelaide Medical School, 2025
Provenance
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