Date of Award

January 2024

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Benjamin Judson

Abstract

Post-treatment surveillance imaging for oropharyngeal squamous cell carcinoma (OPSCC) is guided by the National Comprehensive Cancer Network (NCCN) and often is routinely performed beyond the suggested guidelines. With the advent of biomarker-based disease surveillance, there may be an alternative option that can reduce the cost-burden of post-treatment imaging for OPSCC. This study investigates the comparative cost-effectiveness of a hypothetical miRNA biomarker test for specifically HPV-negative (HPV-) OPSCC post-treatment surveillance and also investigates whether the extra imaging practices that are often employed for both HPV+ and HPV- OPSCC are truly cost-effective in order to inform evidence-based decision making after OPSCC treatment. The cost-effectiveness model was constructed using hypothetical patient cohorts. A Markov model was created to simulate the different post-treatment surveillance options available and probabilities for recurrence at various time-points based on previous literature. A sensitivity analysis was conducted to adjust for variations in cost and biomarker test characteristics. The participants in the model were disease-free patients aged 18+ in the United States who are in remission after completing treatment for OPSCC. Cost was measured in United States dollars ($). The willingness-to-pay threshold (WTP) for the HPV- biomarker cost-effectiveness analysis was $50,000 per quality-adjusted-life-year (QALY) and the WTP when comparing extra imaging for both HPV+ and HPV- OPSCC was $100,000 per QALY. The results of our first analysis investigates the relative cost-effectiveness of the biomarker surveillance strategy for HPV- OPSCC to surveillance practices in accordance with and beyond NCCN guidelines. Here, the NCCN pathway was $4,028.38 more costly and 0.05 QALY more effective than the miRNA pathway. The Extra Imaging pathway was $16,619.83 more costly and 0.18 QALY more effective than the miRNA pathway. The ICER between the miRNA and NCCN strategy was $81,074/QALY and $100,815/QALY between the NCCN and Extra Imaging pathways. The biomarker serum surveillance pathway is more cost-effective than the NCCN approach until the willingness to pay (WTP) threshold exceeds ~$82,000. At the standard WTP threshold of $50,000/QALY, the serum test pathway is more cost-effective. We also determined the theoretical characteristics of a cost-effective miRNA test. Probabilistic analysis revealed a cost-effective miRNA test should cost less than $451.80, have a sensitivity of greater than 57%, and a specificity greater than 50%. The results of our second analysis investigates the cost-effectiveness of additional imaging beyond recommended NCCN surveillance guidelines for HPV+ and HPV- OPSCC. For HPV+ OPSCC, the Extra Imaging pathway was $14,600 more costly and 0.05 QALY more effective than the current NCCN guidelines. The ICER was $266,184/QALY. For HPV- OPSCC, the Extra Imaging pathway was $12,695 more costly and 0.13 QALY more effective than the NCCN guidelines. The ICER was $96,128/QALY. For HPV+ OPSCC, at a WTP threshold of $100,000, the NCCN guidelines are the cost-effective option until the threshold exceeds $266,000. For HPV- OPSCC the Extra Imaging guidelines become the most cost-effective at a WTP of $96,000. In conclusion, the miRNA biomarker strategy is a cost-effective surveillance option for HPV- oropharyngeal cancer compared to currently utilized options. By reducing the reliance on repeated imaging, radiation and in-person follow-up, this strategy can provide more equitable and accessible healthcare. Our modeling also shows that the extra imaging frequently performed does become the optimal cost-effective surveillance strategy for HPV- OPSCC at an acceptable WTP threshold (~$96,000). The current NCCN guidelines without extra imaging remain cost-effective for HPV+ OPSCC.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 04/30/2026

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