Assessing Cost-effectiveness From the LOGICA Trial—Is Laparoscopic Gastrectomy Worth the Cost?

Recent randomized clinical trials have demonstrated equivalent oncologic outcomes between laparoscopic and open gastrectomy for patients with both early and advanced gastric cancer, leading to widespread adoption of minimally invasive gastrectomy.^1-4 The Laparoscopic vs Open Gastrectomy for Gastric Cancer (LOGICA) trial¹ is a multicenter randomized clinical trial that enrolled 227 patients with locally advanced gastric cancer in the Netherlands. Results showed that laparoscopic gastrectomy was associated with longer operative times, yet there were no differences in oncologic outcomes, postoperative complications, or 1-year overall survival between laparoscopic and open gastrectomy.

In this issue of JAMA Surgery, van der Veen et al⁵ publish a detailed cost analysis of the LOGICA trial, comparing quality-adjusted life-years (QALYs) and patient costs up to 1 year post-operatively, and ultimately demonstrate that there is no difference in cost or QALYs between laparoscopic and open approaches. The total cost in the laparoscopic group was 3.0% higher than that in the open group (€26 084 [US $25 965] vs €25 332 [US $25 216]; difference, €752 [US $749]), driven primarily by longer operative times and use of disposable surgical materials with laparoscopy. We congratulate the authors on this prospective analysis and, furthermore, on the use of bottom-up cost modeling, accounting for direct and indirect costs and addressing QALYs that add to the strength of this study.

Because there has been increased awareness of the financial burden associated with oncology, such analyses are of utmost importance. One of the critiques of the use of laparoscopy is the increased cost of the operation secondary to equipment and operative time. However, several trials demonstrated that a laparoscopic approach is associated with lower complication rates and faster recovery.^2,3 We must consider that all cost analyses are not generalizable. Costs of a procedure depend on surgical approach, as well as the institution and specific patient factors. In the LOGICA trial, the reported similar costs could reflect the comparable lengths of stay and complications between approaches. However, in a group that has fewer complications with laparoscopy, lower postoperative hospital costs could offset higher operative costs.

Additionally, there are costs outside of measurable hospital charges that can be difficult to capture but affect overall patient outcomes, including time to recovery, return to work, and receipt of adjuvant chemotherapy. Some studies have shown improved recovery and quality of life after laparoscopic gastrectomy, whereas others have demonstrated a shorter time to receipt of adjuvant therapy.^2,6 These outcomes undoubtedly should be considered a potential cost of each procedure and should be accounted for in surgical decision-making.

This study shows that the potential postoperative benefits of minimally invasive gastrectomy match the increased costs of longer operative time and more expensive materials. Laparoscopic gastrectomy continues to emerge as a feasible alternative to open gastrectomy for gastric cancer resection, and van der Veen et al⁵ suggest that laparoscopic gastrectomy is on par not only with an open approach regarding oncologic outcomes but also financially.