TY - JOUR
T1 - Surveillance vs Standard Surgery and Cost-Effectiveness After Neoadjuvant Chemoradiotherapy for Esophageal Cancer
T2 - Secondary Analysis of a Randomized Clinical Trial
AU - Gangaram Panday, Sanjiv S.G.
AU - Van Klaveren, David
AU - Surgery as Needed for Oesophageal Cancer (SANO) Study Group
AU - Lagarde, Sjoerd M.
AU - Van Der Wilk, Berend J.
AU - Eyck, Ben M.
AU - Rosman, Camiel
AU - Noordman, Bo J.
AU - Valkema, Maria J.
AU - Bisseling, Tanya M.
AU - Coene, Peter Paul L.O.
AU - Dekker, Jan Willem T.
AU - Van Det, Marc J.
AU - Van Dieren, Jolanda M.
AU - Doukas, Michail
AU - Van Esser, Stijn
AU - Fiets, W. Edward
AU - Hartgrink, Henk H.
AU - Heisterkamp, Joos
AU - Hol, Lieke
AU - Klarenbeek, Bastiaan
AU - Kouw, Eva
AU - Kouwenhoven, Ewout A.
AU - Luyer, Misha D.
AU - Mostert, Bianca
AU - Nieuwenhuijzen, Grard A.P.
AU - Oostenbrug, Liekele E.
AU - Oude Voshaar, Martijn
AU - Spaander, Manon C.W.
AU - Steyerberg, Ewout W.
AU - Valkema, Roelf
AU - Van Lanschot, J. Jan B.
AU - Lingsma, Hester F.
AU - Wijnhoven, Bas P.L.
AU - Koch, Arjun D.
AU - Nikkessen, Suzan
AU - van der Gaast, Ate
AU - de Lussanet de la Sablonière, Quido G.
AU - Biermann, Katharina
AU - Oudijk, Lindsey
AU - Dwarkasing, Roy S.
AU - Nuyttens, Joost J.
AU - van der Sluis, Pieter C.
AU - Siersema, Peter D.
AU - Zweers, Serge J.
AU - Aktas, Huseyin
AU - Quispel, Rutger
AU - ten Broek, Marc R.J.
AU - Muller, Karin
AU - Creemers, Geert Jan
AU - Soufidi, Khalida
N1 - Publisher Copyright:
© 2026 Gangaram Panday SSG et al.
PY - 2026/7/27
Y1 - 2026/7/27
N2 - Importance: Active surveillance is noninferior to standard surgery for 2-year survival and improves short-term health-related quality of life among patients with a complete clinical response (CCR) after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer. Although active surveillance reduces the upfront costs of surgery and hospital stay, it requires repeated diagnostic tests and, for some patients, delayed surgery and hospitalization during follow-up. Objective: To assess the cost-effectiveness of active surveillance compared with standard surgery after nCRT. Design, Setting, and Participants: This prespecified cost-effectiveness analysis from a health care perspective conducted at 12 hospitals in the Netherlands as a secondary analysis of the Surgery as Needed for Oesophageal Cancer (SANO) trial, a noninferiority, cluster randomized study, enrolled patients with esophageal cancer who achieved a CCR after nCRT between November 8, 2017, and January 17, 2021, with follow-up for up to 5 years. Data were analyzed on June 1, 2025. Interventions: Active surveillance, consisting of repeated response evaluations at 6, 9, 12, 16, 20, 24, 30, 36, 48, and 60 months after nCRT, compared with standard surgery. Main Outcome and Measures: Incremental cost-effectiveness of active surveillance vs standard surgery and quality-adjusted life-years (QALYs) with 95% CIs up to 5 years were derived with bootstrapping, with 80% of patients (247 of 309) having complete follow-up. Incremental net monetary benefit (iNMB) was calculated at varying willingness-to-pay thresholds. All analyses followed the modified intention-to-treat principle. Costs are given in Euros (currency exchange rate of 1 = US $1.16 as of June 11, 2026). Results: Among 309 patients (198 in the active surveillance group; median age, 69 years [IQR, 63-74 years]; 156 men [79%]; and 111 in the standard surgery group; median age, 68 years [IQR, 61-73 years]; 86 men [77%]), those in the active surveillance group had a mean of 2.99 QALYs (95% CI, 2.73-3.26) at 5 years vs 2.88 QALYs (95% CI 2.69-3.06) in the standard surgery group. Mean health care costs per patient at 5 years were 36733 (95% CI, 33530-40009) in the active surveillance group vs 45106 (95% CI, 39449-51545) in the standard surgery group. The incremental QALY for active surveillance was 0.11 (95% CI, -0.10 to 0.33) and mean costs were 8374 lower (95% CI, 1792-15355) compared with standard surgery. At a willingness-to-pay threshold of 80000 per QALY, the mean iNMB was 17568 (95% CI, -725 to 37497), indicating that active surveillance is cost-effective. Bootstrap analysis showed that 97% of replications fell in the cost-effective region.Conclusions and Relevance:In this secondary analysis of a randomized clinical trial of patients with esophageal cancer achieving a CCR after nCRT, active surveillance was cost-effective over a 5-year horizon compared with standard surgery. Broader implementation of this strategy among appropriately selected patients would most likely reduce health care costs without compromising health outcomes.
AB - Importance: Active surveillance is noninferior to standard surgery for 2-year survival and improves short-term health-related quality of life among patients with a complete clinical response (CCR) after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer. Although active surveillance reduces the upfront costs of surgery and hospital stay, it requires repeated diagnostic tests and, for some patients, delayed surgery and hospitalization during follow-up. Objective: To assess the cost-effectiveness of active surveillance compared with standard surgery after nCRT. Design, Setting, and Participants: This prespecified cost-effectiveness analysis from a health care perspective conducted at 12 hospitals in the Netherlands as a secondary analysis of the Surgery as Needed for Oesophageal Cancer (SANO) trial, a noninferiority, cluster randomized study, enrolled patients with esophageal cancer who achieved a CCR after nCRT between November 8, 2017, and January 17, 2021, with follow-up for up to 5 years. Data were analyzed on June 1, 2025. Interventions: Active surveillance, consisting of repeated response evaluations at 6, 9, 12, 16, 20, 24, 30, 36, 48, and 60 months after nCRT, compared with standard surgery. Main Outcome and Measures: Incremental cost-effectiveness of active surveillance vs standard surgery and quality-adjusted life-years (QALYs) with 95% CIs up to 5 years were derived with bootstrapping, with 80% of patients (247 of 309) having complete follow-up. Incremental net monetary benefit (iNMB) was calculated at varying willingness-to-pay thresholds. All analyses followed the modified intention-to-treat principle. Costs are given in Euros (currency exchange rate of 1 = US $1.16 as of June 11, 2026). Results: Among 309 patients (198 in the active surveillance group; median age, 69 years [IQR, 63-74 years]; 156 men [79%]; and 111 in the standard surgery group; median age, 68 years [IQR, 61-73 years]; 86 men [77%]), those in the active surveillance group had a mean of 2.99 QALYs (95% CI, 2.73-3.26) at 5 years vs 2.88 QALYs (95% CI 2.69-3.06) in the standard surgery group. Mean health care costs per patient at 5 years were 36733 (95% CI, 33530-40009) in the active surveillance group vs 45106 (95% CI, 39449-51545) in the standard surgery group. The incremental QALY for active surveillance was 0.11 (95% CI, -0.10 to 0.33) and mean costs were 8374 lower (95% CI, 1792-15355) compared with standard surgery. At a willingness-to-pay threshold of 80000 per QALY, the mean iNMB was 17568 (95% CI, -725 to 37497), indicating that active surveillance is cost-effective. Bootstrap analysis showed that 97% of replications fell in the cost-effective region.Conclusions and Relevance:In this secondary analysis of a randomized clinical trial of patients with esophageal cancer achieving a CCR after nCRT, active surveillance was cost-effective over a 5-year horizon compared with standard surgery. Broader implementation of this strategy among appropriately selected patients would most likely reduce health care costs without compromising health outcomes.
UR - https://www.scopus.com/pages/publications/105046165660
U2 - 10.1001/jamanetworkopen.2026.24615
DO - 10.1001/jamanetworkopen.2026.24615
M3 - Article
C2 - 42507446
AN - SCOPUS:105046165660
SN - 2574-3805
VL - 9
JO - JAMA network open
JF - JAMA network open
IS - 7
M1 - e2624615
ER -
SDG 3 Good Health and Well-being