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Cost-effectiveness Analysis Comparing Conventional, Hypofractionated, and Intraoperative Radiotherapy for Early-Stage
Ashish A Deshmukh1, Shervin M Shirvani1, Lincy Lal1
1Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL; Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ; The University of Texas Health Science Center at Houston School of Public Health, Houston, TX; The University of Texas Health Science Center at Houston Medical School, Center for Clinical Research and Evidence-Based Medicine, Houston, TX; Department of Health Services Research and Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
Background:
Early-stage breast cancer is among the most prevalent and costly malignancies treated in the American health care system. Adjuvant radiotherapy after lumpectomy represents a substantial portion of breast cancer expenditures. The relative value of novel radiotherapeutic approaches such as intraoperative radiotherapy (IORT) and hypofractionated whole breast irradiation (HF-WBI) compared with conventionally fractionated whole breast irradiation (CF-WBI) is unknown. Therefore, we used prospectively collected outcomes from randomized clinical trials (RCTs) to compare the cost-effectiveness of these approaches.
Methods:
We constructed a decision-analytic model that followed women who were treated with lumpectomy for early-stage breast cancer. Recurrence, mortality, complication rates, and utilities (five-year radiation-associated quality of life scores), were extracted from RCTs. Costs were based on Medicare reimbursement rates. Cost-effectiveness from societal and health care sector perspectives was estimated considering two scenarios-the first assumes that radiation-associated disutility persists five years after treatment, and the second assumes that disutility discontinues. Lifetime outcomes were summarized using incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses evaluated the robustness of the results.
Results:
HF-WBI dominated CF-WBI (ie, resulted in higher quality-adjusted life-years [QALYs] and lower cost) in all scenarios. HF-WBI also had a greater likelihood of cost-effectiveness compared with IORT; under a societal perspective that assumes that radiation-associated disutility persists, HF-WBI results in an ICER of $17 024 per QALY compared with IORT with a probability of cost-effectiveness of 80% at the $100 000 per QALY willingness-to-pay threshold. If radiation-associated disutility is assumed to discontinue, the ICER is lower ($11 461/QALY), resulting in an even higher (83%) probability of relative cost-effectiveness. The ICER was most sensitive to the probability of metastasis and treatment cost.
Conclusions:
For women with early-stage breast cancer requiring adjuvant radiotherapy, HF-WBI is cost-effective compared with CF-WBI and IORT.
