Cost-Effectiveness of Prophylactic Cranial Irradiation With Hippocampal Avoidance in Limited Stage Small Cell Lung Cancer

Abstract

The recently reported Chest Radiotherapy Extensive Stage Trial (CREST) showed that administering thoracic radiation therapy (TRT) after a response to first-line chemotherapy improves 2-year overall (OS) and progression-free survival, without an increase in adverse events, in patients with extensive stage small cell lung cancer (ES-SCLC). We evaluated the cost-effectiveness of adding TRT to chemotherapy and prophylactic cranial irradiation (PCI) in ES-SCLC patients. Materials/Methods: Using a partitioned survival model, a cost-utility analysis was performed to compare strategies of TRT (30 Gy in 10 fractions via 3-D conformal RT) plus PCI versus PCI alone. The time horizon was limited to 24 months, the median follow-up of CREST. OS was partitioned into three mutually exclusive health states: alive with no progression (ANP), alive with progression (AWP), and dead. The proportion of patients in each health state over time was based on the empirical survival functions reported in CREST. Institutional treatment costs from a payer perspective were used while utilities were derived from the published literature. Incremental cost-effectiveness ratios (ICER) were calculated per quality-adjusted life year (QALY) using a 3% discount rate. Sensitivity analyses addressed plausible ranges of uncertainty in key variables including costs, utilities, and the TRT survival benefit.

The Economic Burden of Small Cell Lung Cancer: A Systematic Review of the Literature

“…The assessed publications received a high-quality score, ranging from 73.1 to 91.7% (see Table 2 ). Four publications could not be assessed in this way as they were abstracts or posters only and therefore could not be scored [ 22 , 26 – 28 ]. However, due to the paucity of data retrieved from the primary search, these publications were included in the final SLR.…”

“…Several publications reported on direct costs of extensive-stage SCLC specifically [ 12 , 15 – 19 , 21 , 22 , 25 , 27 ]. Kang et al investigated the costs of SCLC management and found that the median cost of lung cancer in Australia was highest for limited-stage SCLC ($19,046 vs. $12,688 for extensive-stage) [AU$, review of patient records 2005–2008, applying 2005 Australian Medicare Benefits Schedule costings, adjusted to 2016 US$].…”

“…Seven other publications reported on extensive- and limited-stage SCLC, however the costs reported were not separated by extensive and limited SCLC [ 12 , 15 , 18 , 19 , 21 , 22 , 25 ].…”

“…Prophylactic therapy costs were reported frequently, with two modelling and one observational publication reporting on the direct costs of multiple prophylactic therapies, or presenting mean costs of prophylactic therapy [ 22 – 24 ]. Timmer-Bonte et al investigated the economic burden of secondary prophylactic use of different prophylactic strategies in extensive-stage SCLC patients at risk of febrile neutropenia in The Netherlands and found that the most expensive strategy was antibiotics plus granulocyte colony-stimulating factor (G-CSF), with a mean cost of $13,338 per patient (converted from 2002 € to 2016 US$; original cost year derived from a further publication on the same study, cited within the captured publication) [ 41 ] (Table 7 ).…”

“…The cost of PCI with hippocampal avoidance was reported as $13,377.61 versus $6388.28 for PCI in limited-stage SCLC patients in the US (Medicare’s 2014 reimbursement rate adjusted to 2016 US$) [ 22 ].…”