Cost‐effectiveness analysis of neurocognitive‐sparing treatments for brain metastases

Abstract

BACKGROUND: Decisions regarding how to treat patients who have 1 to 3 brain metastases require important tradeoffs between controlling recurrences, side effects, and costs. In this analysis, the authors compared novel treatments versus usual care to determine the incremental cost-effectiveness ratio from a payer's (Medicare) perspective. METHODS: Cost-effectiveness was evaluated using a microsimulation of a Markov model for 60 one-month cycles. The model used 4 simulated cohorts of patients aged 65 years with 1 to 3 brain metastases. The 4 cohorts had a median survival of 3, 6, 12, and 24 months to test the sensitivity of the model to different prognoses. The treatment alternatives evaluated included stereotactic radiosurgery (SRS) with 3 variants of salvage after recurrence (whole-brain radiotherapy [WBRT], hippocampal avoidance WBRT [HA-WBRT], SRS plus WBRT, and SRS plus HA-WBRT). The findings were tested for robustness using probabilistic and deterministic sensitivity analyses. RESULTS: Traditional radiation therapies remained cost-effective for patients in the 3-month and 6-month cohorts. In the cohorts with longer median survival, HA-WBRT and SRS plus HA-WBRT became cost-effective relative to traditional treatments. When the treatments that involved HA-WBRT were excluded, either SRS alone or SRS plus WBRT was cost-effective relative to WBRT alone. The deterministic and probabilistic sensitivity analyses confirmed the robustness of these results. CONCLUSIONS: HA-WBRT and SRS plus HA-WBRT were cost-effective for 2 of the 4 cohorts, demonstrating the value of controlling late brain toxicity with this novel therapy. Cost-effectiveness depended on patient life expectancy. SRS was cost-effective in the cohorts with short prognoses (3 and 6 months), whereas HA-WBRT and SRS plus HA-WBRT were cost-effective in the cohorts with longer prognoses (12 and 24 months). Cancer 2015;121:4231-9. V C 2015 American Cancer Society.KEYWORDS: cognition disorders, computer-assisted radiotherapy, cost-effectiveness analysis, image-guided radiotherapy, secondary brain neoplasm. INTRODUCTIONBrain metastases are the most common intracranial tumors in adults and are a morbid consequence of disseminated cancer. Uncontrolled brain metastases cause headaches, neurocognitive dysfunction, seizures, and eventually death. 1 With improvements in systemic treatment and the more routine use of magnetic resonance imaging (MRI) for surveillance, the incidence of brain metastases is likely to continue to increase. 1 Given the inadequate penetration of systemic therapies across the blood-brain barrier, cranial irradiation remains the standard treatment for brain metastases. Although radiation treatment can reduce or eliminate the morbidity caused by intracranial tumors, it can also cause neurocognitive toxicity, including cognitive deterioration and cerebellar dysfunction. 2 The recognition that traditional whole-brain radiotherapy (WBRT) is associated with a significant tradeoff in terms of benefit versus harm has led to recent developments of newe...

A matched-pair analysis comparing whole-brain radiotherapy with and without a stereotactic boost for intracerebral control and overall survival in patients with one to three cerebral metastases

“…Another aspect, which needs to be considered, is cost-effectiveness [18]. In a cost-effectiveness analysis published in 2015 that compared neuro-cognitive sparing radiotherapy programs to WBRT alone in patients with one to three brain metastases, hippocampal sparing WBRT plus a stereotactic boost proved to be cost-effective when compared to WBRT alone in patient groups with a median survival pf 12 months or longer following radiotherapy [20]. Moreover, WBRT plus a boost to the metatatic sites can be safely perfomed with volumetric modulated arc therapy (VMAT) in one course as WBRT plus a simultaneous integrated boost (SIB) [21].…”

Prognostic factors for survival in colorectal cancer patients with brain metastases undergoing whole brain radiotherapy: multicenter retrospective study

“…Administration of HA-WBRT could be justified in patients with longer expected survival because the technique can mitigate neurocognitive dysfunction after WBRT. In patients with short life expectancy, however, conventional WBRT may have a better rationale considering its shorter planning time and lower cost 21 .…”

Health State Utilities for Patients with Brain Metastases

“…The current study is critical for future comparative and cost-effectiveness studies comparing forms of SRS—including GKRS and CyberKnife—and WBRT. For example, there are several emerging studies examining neurocognitive outcomes with hippocampal-sparing WBRT; however, these rely on provider estimates of utility scores rather than directly quantified utilities using a validated technique, as presented in the current study [ 25 - 29 ].…”