Lifetime cost-effectiveness analysis of intraoperative radiation therapy versus external beam radiation therapy for early stage breast cancer

Abstract

BackgroundTo date no one has examined the quality of life and direct costs of care in treating early stage breast cancer with adjunct intraoperative radiation therapy (IORT) versus external beam radiation therapy (EBRT) over the life of the patient. As well no one has examined the effects of radiation exposure with both therapies on the longer term sequelae. The purpose of this analysis was to examine the cost-effectiveness of IORT vs. EBRT over the life of the patient.MethodsA Markov decision-analytic model evaluated these treatment strategies in terms of the direct costs in treating patients over their lifetime (including the downstream costs associated with radiation exposure) and the resultant quality of life of these patients. Medicare reimbursement amounts in treating patients were used for acute, steady state, recurrent cancer(s), and complications associated with radiation exposure. Quality adjusted life years (QALYs) derived from the medical literature were assessed with each of these states. Life expectancies as well were derived from the medical literature. Cost-effectiveness was evaluated for dominance and net monetary benefit [at a willingness to pay (WTP)] of $50,000/QALY. Sensitivity analysis was also performed.ResultsIORT was the dominant (least costly with greater QALYs) versus EBRT: total costs over the life of the patient = $53,179 (IORT) vs. $63,828 (EBRT) and total QALYs: 17.86 (IORT) vs. 17.06 (EBRT). At a willingness to pay of $50,000 for each additional QALY, the net monetary benefit demonstrated that IORT was the most cost effective option: $839,815 vs. $789,092. The model was most sensitive to the probabilities of recurrent cancer and death for both IORT and EBRT.ConclusionIORT is the more valuable (lower cost with improved QALYs) strategy for use in patients presenting with early stage ER+ breast cancer. It should be used preferentially in these patients.Electronic supplementary materialThe online version of this article (10.1186/s12962-017-0084-5) contains supplementary material, which is available to authorized users.

‘Biggest factors in having cancer were costs and no entitlement to compensation’—The determinants of out‐of‐pocket costs for cancer care through the lenses of rural and outer metropolitan Western Australians

“…Timely adoption of new tests and treatments when proven to be cost‐effective and their inclusion in MBS could provide some relief for people experiencing high OOPE. For example, the value of intraoperative radiotherapy in terms of cost to the health care system, quality of life and clinical outcomes for patients with early breast cancer has been well documented 20,21 . While the Australian government has provided a MBS item number for the procedure, it has not been widely accepted, nor is it routinely discussed with rural patients as an option that might be more convenient and acceptable for radiotherapy treatment (personal communications with author CS).…”

Partial breast irradiation with CyberKnife after breast conserving surgery: a pilot study in early breast cancer

“…With the technical advantages over existing PBI platforms are evident, potential disadvantages exist with CK-APBI. We are aware of the high cost of CK, especially if compared with IORT that, to date, is the most cost effective APBI option [ 48 ]. A more accurate cost analysis will be subject to future evaluations: the impact of such a sophisticated technique in protecting normal tissues from unnecessary high-dose irradiation, and consequently lowering toxicities, and its power in treatment intensification, with maximal target coverage and potential reduction of local recurrences may equal the initial costs for the health system.…”

Cost-effectiveness analysis of intraoperative radiation therapy versus external beam radiation therapy for the adjuvant treatment of early breast cancer: A systematic review

“…All studies were used a Markov modeling approach, except the studies of Shah et al ( 23 ) and Vaidya et al ( 25 ) that used reimbursement models or were trial-based. Two studies were applied societal perspectives ( 20 , 23 ), two used a payer perspective ( 22 , 26 ), one study both societal and health care sector ( 21 ) and the remaining studies reported results from the perspective of the National Health Service (NHS) ( 8 , 24 , 25 ). All studies used quality-adjusted life-years (QALYs) as the effectiveness outcome.…”

“…All studies used quality-adjusted life-years (QALYs) as the effectiveness outcome. One study applied a 5 years’ time horizon ( 25 ), three studies a 10 years’ time horizon ( 20 , 23 , 24 ), two studies a 40 years’ time horizon ( 8 , 26 ) and two studies considered a lifetime horizon ( 21 , 22 ). Sensitivity analysis was conducted in the majority of included studies (N=7) although the type of approaches varied ( 8 , 20 - 22 , 24 - 26 ).…”

“…Quality scores ranged from 7 to 23 out of a maximum value of 24 points, with an average score of 17 ( Table 2 ). Five studies were classified in the category of “high quality” ( 8 , 22 , 24 , 25 ) one into ( 20 ) the “medium quality” category and two studies ( 23 , 26 ) fell into the “low” reporting quality.…”