The cost-benefit of 3D conformal radiation therapy compared with conventional techniques for patients with clinically localized prostate cancer.

The present health care environment, not only in the United States but also throughout the world, is dominated by concerns of increasing costs and limited resources to care for our sick and aging population. There is a great deal of emphasis on scrutiny of technology or innovative approaches to administration of medical services, and oncology is not an exception. The main purposes of technology assessment are to: (a) determine the appropriateness of a new procedure consistent with the health care organization’s mission and strategy plan, (b) determine safety, efficacy, and cost effectiveness, (c) establish appropriate indications for the new technology, and (d) devise quality improvement methods to optimize the use of innovative technology (1). In the article by Horwitz et al. (2), the authors report no difference in the mean total charges for treatment of patients with localized carcinoma of the prostate with either threedimensional (3D) conformal or conventional external beam irradiation. Noteworthy, Medicare charges may be a reflection of cost of therapy to society, but they do not represent the true cost of treatment in a business sense. It is mandatory, in the present system in which reimbursement for services is arbitrarily set by government (Health Care Financing Administration) or corporate entities (HMOs), that we develop accurate and realistic methodology to calculate cost of delivering a specific professional service (3–5). Although the main emphasis of the Horwitz et al. (2) publication is cost effectiveness, they do point out that recent publications have shown the efficacy of 3D conformal irradiation in improving biochemical disease-free survival in comparison with patients treated with conventional techniques (added value). Technology assessment is a complex process; it involves not only financial considerations and therapeutic outcomes (such as locoregional tumor control and survival), but must also make an effort to assess the morbidity of treatment, quality of life, and productivity of the patients after therapy (6). As Hayman et al. (7) have pointed out, economic considerations of a diagnostic or therapeutic intervention may be analyzed from several standpoints. Efficacy relates to outcome in terms of tumor control or survival; cost effectiveness relates to the cost of the intervention and availability to a specific population. Cost benefit incorporates the concept of added value with improved outcome for the new diagnostic or therapeutic procedure, and cost utility, in addition to cost effectiveness (additional cost and impact on outcome of a new intervention), measures improved quality of life and productivity of the population after treatment. From a financial standpoint, the lowest cost treatment is usually preferred, and that is the emphasis that managed care programs have given to many of their coverage policies. As a consequence of this shift on emphasis of objectives of the health care system, there is a tendency to decrease the importance of quality of care given to the patient. However, this is a shortsighted view, as it has been demonstrated that the cost of treating a patient throughout his/her lifetime is three to four times higher when the initial treatment is unsuccessful (appearance of recurrence or metastasis) in comparison with a patient initially treated successfully (6). Also, there is a great deal of financial benefit if the new treatment approach will result in decreased morbidity and complications, the treatment cost of which must be incorporated in any analysis of global cost benefit. Models have been constructed using available data on natural history of a tumor, prognostic factors, efficacy of a given staging or therapeutic modality (based on actual outcome analysis), and the cost of providing services for these patients. With the growing body of information on epidemiological data and more sophisticated cost-computing techniques, as well as reimbursement for health care services to providers, it should be relatively easy to demonstrate the cost benefit of innovative technology. A challenge for future health care initiatives, including managed care organizations or capitated systems, will be to strive for the most competitive cost (lowest cost and equally