# Radiation Oncology/Cost-Effectiveness

* Front Page: Radiation Oncology | RTOG Trials | Randomized Trials

## Quality of Care

* American College of Surgeons; 2009 PMID 19466738 -- "Using the NCDB for cancer care improvement: an introduction to available quality assessment tools." (Raval MV, J Surg Oncol. 2009 Jun 15;99(8):488-90.)
** Description of National Cancer Database (NCDB) and how it can be used to improve quality of cancer care in the U.S.

## Utilization

* Ghent University; 2008 PMID 18374290 -- "Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical studies." (Veldeman L, Lancet Oncol. 2008 Apr;9(4):367-75.)
** Review of IMRT evidence
** Conclusion: Evidence of reduced toxicity; local control and overall survival inconclusive
* CCORE, Australia; 2005 PMID 16080176 -- "The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines." (Delaney G, Cancer. 2005 Sep 15;104(6):1129-37.)
** Evidence-based estimate of RT ~52% of patients with cancer. Monte Carlo estimates ranged from 51.7 - 53.1%
* University of Minnesota; 2002 (1991-1996) PMID 12187168 -- "Studying radiation therapy using SEER-Medicare-linked data." (Virnig BA, Med Care. 2002 Aug;40(8 Suppl):IV-49-54.)
** Comparison of SEER and Medicare (MedPAR Part B and Outpatient) data. Cohort of breast, endometrial, lung, prostate, or rectal cancer patients.
** Outcome: Agreement between SEER and Medicare for lung 88%, prostate 93%, rectal cancer 94%, breast cancer 94%, endometrial cancer 95%
** Conclusion: High level of agreement between SEER and Medicare data, suggesting either source can be used to asses RT-related treatment patterns

## Health Policy

* Memorial Sloan Kettering; 2009 Full paper -- "Limits on Medicare's Ability to Control Rising Spending on Cancer Drugs" (Bach PB, New England Journal Of Medicine, 2009)
* 21st Century Oncology; 2008 PMID 18954812 -- "A changing paradigm in the study and adoption of emerging health care technologies: coverage with evidence development." (Wallner PE, J Am Coll Radiol. 2008 Nov;5(11):1125-9.)
** Introduction of new technologies without "significant evidence" places an increasing burden on health care delivery system. Review of "coverage with evidence development" reimbursement strategy

## Economic Analysis

* Tufts; 2010 PMID 20056956 -- "When is cancer care cost-effective? A systematic overview of cost-utility analyses in oncology." (Greenberg D, J Natl Cancer Inst. 2010 Jan 20;102(2):82-8. Epub 2010 Jan 7.)
* MD Anderson; 2008 PMID 18596196 -- "Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean?" (Shih YC, CA Cancer J Clin. 2008 Jul-Aug;58(4):231-44.)
** Overview of economic evaluations
* Harvard; 1996 PMID 8690653 -- "Economic analyses in health care: an introduction to the methodology with an emphasis on radiation therapy." (Hayman J, Int J Radiat Oncol Biol Phys. 1996 Jul 1;35(4):827-41.)
* Intervention ("NEW") is always compared to another intervention strategy, including "no treatment" strategy ("STANDARD")
* Cost Minimization
** Assumes that intervention benefit is comparable; it can thus be eliminated from analysis
** Only cost of NEW intervention is compared to the cost of STANDARD intervention
** Unit = dollars
* Cost Effectiveness
** Cost of intervention is related to its impact on a clinically relevant endpoint ("effectiveness")
** Years of life saved (survival) is most commonly used endpoint
** Incremental cost-effectiveness ratio (ICER) is the incremental cost divided by the incremental benefit of NEW intervention over STANDARD intervention
** Unit = dollars per year-life-saved
** Commonly accepted "cost-effectiveness" threshold is $50,000 - $100,000 per year life saved
* Cost Utility
** The endpoint (eg survival) is modified by quality of life measures ("utility") due to:
*** Survival is insensitive to treatment-related side-effects (eg xerostomia), which may make survival not as valuable to a patient
*** Survival is insensitive to palliative benefits of treatment (eg relief of dyspnea in NSCLC)
*** Survival is insensitive to prolongation of disease-free period (eg longer life without painful bone mets)
** Utility is generally 0-1 (0 represents death, 1 represents perfect health)
** Effectiveness (survival benefit) is then multiplied by utility to get Quality-Adjusted Life Year (QALY)
** Incremental cost-effectiveness ratio is the incremental cost divided by the incremental QALY benefit of NEW intervention over STANDARD intervention
** Unit = dollars per QALY
** Commonly accepted "cost-effectiveness" threshold is $50,000 - $100,000 per QALY
* Cost Benefit
** The benefit of intervention (improved survival, less toxicity, longer DFS) is converted to dollars
** Cost of intervention is in dollars
** The cost-benefit of NEW and STANDARD treatments is calculated as benefit (dollars) minus cost (dollars)
** The incremental cost-benefit is the difference between NEW and STANDARD, and is beneficial if it is >0
** There is a lot of controversy about assigning dollar value to benefits such as lower toxicity

## RT Cost Estimates

* Lyon; 2009 PMID 19493690 -- "[The cost of respiration-gated radiotherapy in the framework of a clinical research programme "STIC"] - [Article in French]" (Remonnay R, Cancer Radiother. 2009 Jun 1. [Epub ahead of print])
** Prospective nonrandomized cost study. 365 patients breast or lung cancer, RT +/- respiratory gating.
** Outcome: Cost lung no gating euro 1256 vs. gating 1807; breast 996 vs. 1510. Overcosts due to extra working time of staff, and extra use of equipment
** Conclusion: Medical reimbursement largely underestimate costs related to innovation
* Calgary, Canada; 2008 PMID 18237802 -- "The cost of radiation therapy." (Ploquin NP, Radiother Oncol. 2008 Feb;86(2):217-23. Epub 2008 Jan 30.)
** Literature review. 11 publications
** Conclusion: Costs for RT seem to be converging
* Michigan 2000 PMID 10802374 -- "A comparison of two methods for estimating the technical costs of external beam radiation therapy." (Hayman JA, Int J Radiat Oncol Biol Phys. 2000 May 1;47(2):461-7.)
** Comparison of using Medicare data (converting Medicare charges into costs via Medicare Cost-to-Charge Ratios, CCR) vs. direct procedure-specific cost estimates from cost-accounting systems (CAS)
** CCR vs CAS: Palliative simple $1,285 vs. $1,195 (+8%); palliative complex $2,345 vs. $1,769 (+33%); curative breast $6,757 vs. $4,850 (+39%); curative prostate $9,453 vs. $7,498 (+26%)
** Conclusion: for complex treatments (most of EBRT), technical cost estimates much higher using Medicare CCR vs. internal CAS. This may impact cost-effectiveness analysis

## Breast

* Harvard
** 2009 PMID 18963542 -- "Partial-breast irradiation versus whole-breast irradiation for early-stage breast cancer: a cost-effectiveness analysis" (Sher DJ, Int J Radiat Oncol Biol Phys. 2009 Jun 1;74(2):440-6. Epub 2008 Oct 27.)
*** Markov model. ICER estimate for PBI vs WBRT for ER+ postmenopausal women with early stage BCA. External beam PBI (EB-PBI) and Mamosite PBI (MS-PBI) compared
*** ICER for WBRT compared with EB-PBI $630,000/QALY, but MS-PBI much worse than both
*** Conclusion: EB-PBI most cost-effective over a wide range of assumptions
** 2008 PMID 17967514 -- "Partial breast irradiation versus whole breast radiotherapy for early-stage breast cancer: a decision analysis." (Sher DJ, Int J Radiat Oncol Biol Phys. 2008 Feb 1;70(2):469-76. Epub 2007 Oct 29.)
*** Markov model to compare quality-adjusted life expectancy (QALE) for APBI vs WBRT in ER+ early stage BCA over 15 years
*** Outcome: QALE for 40-year old 12.6 years, for 55-year old 12.1 years. QALE highly sensitive to patient preferences
*** Conclusion: For most utility values, APBI preferred treatment modality
* Michigan
** 2005 PMID 15936561 -- "A cost comparison analysis of partial versus whole-breast irradiation after breast-conserving surgery for early-stage breast cancer." (Suh WW, Int J Radiat Oncol Biol Phys. 2005 Jul 1;62(3):790-6.)
*** Payer costs (2003 Medicare) and patient costs estimated for 1) WBRT-Boost 60/30, 2) WBRT 50/25, 3) WBRT-AC 42.5/16, 4) WBRT-IMRT 60/30, 5) APBI-MammoSite, 6) APBI-HDR, 7) APBI-3DCRT 38.5/10 BID, 8) APBI-IMRT 38.5/10 BID
*** Least costly: WBRT using External Beam (APBI-3DCRT)
** 2005 PMID 15752884 -- "Cost-effectiveness of radiation therapy following conservative surgery for ductal carcinoma in situ of the breast." (Suh WW, Int J Radiat Oncol Biol Phys. 2005 Mar 15;61(4):1054-61.)
*** Markov model, 55-yeard old woman, DCIS, BCS. 12-year rates: invasive 18% vs. 8%, noninvasive 16% vs. 9% (NSABP B-17 data)
*** RT incemental cost: overall $3300 (2002 Medicare schedule), initial $8700, due to higher LR salvage costs.
*** Incremental cost-effectiveness rate (ICER): $36,700 per QALY
*** Conclusion: should not withold RT because of cost-effectiveness
** 2000 PMID 10637242 -- "Cost-effectiveness of adding an electron-beam boost to tangential radiation therapy in patients with negative margins after conservative surgery for early-stage breast cancer." (Hayman JA, J Clin Oncol. 2000 Jan;18(2):287-95.)
*** Markov model. Early stage BCA, BCS with SM-. Addition of E-boost to tangential fields. Data from Lyon trial (reduction of LR by 2% at 10 years, no OS impact)
*** Cost $2,008; 0.0065 QALY, ICER >$300,000
*** Conclusion: Cost-effectiveness for E-boost well above commonly cited threshold of $50,000
** 1999 PMID 10378968 -- "Is the use of radiation therapy after mastectomy cost-effective?" (Hayman JA, Semin Radiat Oncol. 1999 Jul;9(3):287-91.)
*** Review
** 1998 PMID 9508186 -- "Cost-effectiveness of routine radiation therapy following conservative surgery for early-stage breast cancer." (Hayman JA, J Clin Oncol. 1998 Mar;16(3):1022-9.)
*** Markov model, 60-year old women, BCS +/- RT
*** Addition of RT: cost increase $9,800 per patient; no change in life expectancy; increase in 0.35 QALY/patient = ICER $28,000/QALY
*** Conclusion: RT after BCS is cost-effective compared to other accepted medical interventions
* Stockholm 2005 (Sweden) PMID 15885828 -- "Economic evaluation of proton radiation therapy in the treatment of breast cancer." (Lundkvist J, Radiother Oncol. 2005 May;75(2):179-85.)
** Markov model. 55-year old women, left-sided BCA. Treated with proton RT
** Cost per QALY: Euro 67,000 (considered not cost-effective). However, high risk-population for cardiac disease (mortality risk 2X) cost Euro 35,000. This is ~5% of treated patients in Sweden
* Penn 2002 PMID 12039934 -- "Decision-analytic model and cost-effectiveness evaluation of postmastectomy radiation therapy in high-risk premenopausal breast cancer patients." (Lee JH, J Clin Oncol. 2002 Jun 1;20(11):2713-25.)
** Markov model. Premenopausal, LN+ women. Postmastecomy +/- RT. 15-year outcome, discount 3%
** 15-year predicted relapse-free survival: no RT 48% vs. RT 55%, 0.29 years life gained
** Cost: no RT $40,800 vs. 48,100. ICER $24,900, QALY 22,600
* Ontario 2000 PMID 11072153 -- "A cost-outcome analysis of adjuvant postmastectomy locoregional radiotherapy in premenopausal node-positive breast cancer patients." (Dunscombe P, Int J Radiat Oncol Biol Phys. 2000 Nov 1;48(4):977-82.)
** Premenopausal, LN+ women. Post-mastectomy + RT
** Cost CAD 7,000 (in 1997 canadian dollars); benefit 0.5 life years, ICER CAD 14,000; 0.45 QALY at 10 years, QALY CAD 15,600

## Medulloblastoma

* Karolinska 2005 PMID 15637691 -- "Cost-effectiveness of proton radiation in the treatment of childhood medulloblastoma." (Lundkvist J, Cancer. 2005 Feb 15;103(4):793-801.)
** Markov model. 5-year old children. Consequences of proton RT
** Euro 23,600 cost saving (mainly due to reduction in IQ loss and GHD); 0.68 QALY/patient
** Conclusion: Protons cost-effective, and cost-saving compared to photons with proper patient selection

## Lung

* Toronto, 2004 PMID 15609808 -- "Estimating the benefit and cost of radiotherapy for lung cancer." (Barbera L, Int J Technol Assess Health Care. 2004 Fall;20(4):545-51.)
** Benefit from lit review, cost using published canadian data; 2001 Canadian Dollars (CAD).
** Mean benefit: Curative intent 7 months of survival, palliative intent 3 months of symptom control
** Cost: CAD 9,881 per life year gained, CAD 13,938 per year symptom control gained
** Conclusion: RT relatively inexpensive

## Rectum

* Swedish Rectal Trial, 2002 PMID 12377315 -- "Cost-effectiveness of preoperative radiotherapy in rectal cancer: results from the Swedish Rectal Cancer Trial." (Dahlberg M, Int J Radiat Oncol Biol Phys. 2002 Nov 1;54(3):654-60.)
** 8 year F/U. 98/1168 randomly selected patients from main trial from single region.
** Total costs: RT USD 35,300 vs. surgery alone USD 30,000
** Survival benefit 21 months - cost of year saved USD 3,654. Sensitivity analysis worst case USD 15,228

## Spinal Cord Mets

* Please see RTOG 97-14 on the Bone metastases page

## Protons

* Also see above in organ-specific sections
* Stockholm 2005 (Sweden) PMID 16332592 -- "Proton therapy of cancer: potential clinical advantages and cost-effectiveness." (Lundkvist J, Acta Oncol. 2005;44(8):850-61.)
** Markov model. Four scenarios: left-sided breast cancer, prostate cancer, H&N cancer, and medulloblastoma
** Conclusion: average cost per QALY: GBP 10,130. Proton facility investment may be cost-effective

## Erythropoietin

* Princess Margaret, 1998 PMID 9874467 -- "What are cancer patients willing to pay for prophylactic epoetin alfa? A cost-benefit analysis." (Ortega A, Cancer. 1998 Dec 15;83(12):2588-96.)
** Willingness to pay (WTP) analysis
** Editorial PMID 9874443

## Conflict of Interest

* Georgetown; 1992 PMID 1406881 -- "Consequences of physicians' ownership of health care facilities--joint ventures in radiation therapy." (Mitchell JM, N Engl J Med. 1992 Nov 19;327(21):1497-501.)
** Radiation therapy joint ventures in Florida reviewed, and data compared to rest of US
** Outcome: None in inner city or rural areas. Delivered 53% more RT, had 42% higher charges, and spent 18% less time with each patient. Mortality comparable
** Conclusion: Joint ventures in RT have adverse effects on patients' access to care, increase use of services and costs substantially, and cause no improvement in quality