M201 - The Price of Patience: Patient Charges of a “Watch and Wait” Approach for Rectal Cancer at a Safety Net Hospital

Purpose/Background: For patients with locally advanced rectal cancer (LARC) who have had a complete clinical response (cCR) following total neoadjuvant therapy (TNT), there is growing interest in applying a “Watch and Wait” (WW) or non-operative management (NOM) approach. Such patients undergo a significantly more rigorous surveillance regimen compared to that recommended for patients undergoing standard total mesorectal excision (TME) surgery. Understanding potential patient costs for standard and NOM approaches may be valuable for treatment counseling, particularly for underinsured individuals.

Methods/Interventions: Financial data from a single institution in an underserved region were analyzed to derive representative patient charge models (NOM n=9; TME/ileostomy and reversal n=4). All patients had distal LARC and underwent equivalent TNT regimens. Charge differences were examined from the time of determination of cCR. Analyses included mean charges for appointments, sigmoidoscopy, MRI, CT, CEA and operative costs. Mean charges were used to project 5-year costs for both groups based on an international consensus schedule for NOM and national standard guidelines for post-operative surveillance (Table 1). Assumptions for this model include successful NOM without regrowth/recurrence and TME without major complications. Patient charges do not necessarily reflect actual collections.

Results/Outcomes: Over 5 years, total costs for the NOM arm (Figure 1; $116,251) were 35% less than that for the TME arm ($178,422). Surgery charges alone accounted for $120,058, exceeding the entire 5-year costs associated with NOM. The annual mean surveillance cost for NOM was $23,250, compared to $11,673 for the surveillance-only costs for the TME arm. The average expense of TME with diverting loop ileostomy was $83,857 and $36,201 for a diverting loop ileostomy reversal.

Conclusion/Discussion: At our institution, a successful NOM approach in the setting of a cCR following TNT for LARC is associated with substantially reduced 5-year costs compared to standard TME. Expenses linked to TME/ileostomy and subsequent reversal alone exceeded the cumulative costs of the NOM approach. The potential financial implications of standard vs. NOM approaches may represent an additional component for counseling, particularly for patients at risk for financial toxicity. Institution and/or patient-specific model calculations may thus be of value in decision-making. These comparisons may serve as a springboard for more comprehensive decision tree analyses that incorporate risks of complications, regrowth and recurrence.