Adjuvant breast radiotherapy: How to trade-off cost and effectiveness?

A series of health economic evaluations (HEE) has analysed the efficiency of new fractionation schedules and techniques for adjuvant breast radiotherapy. This overview assembles the available evidence and evaluates to what extent HEE-results can be compared.

Based on a systematic literature review of HEEs from 1/1/2000 to 30/10/2016, all cost comparison (CC) and cost-effectiveness analyses (CEA) comparing different adjuvant breast radiotherapy approaches were analysed. Costs were extracted and converted to Euro 2016 and costs per QALY were summarized in cost-effectiveness planes.

Twenty-four publications are withheld, comparing different fractionation schedules and/or irradiation techniques or evaluating the value of adding radiotherapy. Normofractionation and intensity-modulated, interstitial or intraluminal techniques are important cost-drivers. Highest reimbursements are observed in the US, but may overestimate the real cost. Hypofractionation is cost-effective compared to normofractionation, the results of partial breast irradiation are less unequivocal. Intra-operative and external beam approaches seem the most cost-effective for favourable risk groups, but whole breast irradiation is superior in terms of health effect and omission of radiotherapy in terms of costs.

Hypofractionation may be considered the most relevant comparator for new strategies in adjuvant breast radiotherapy, with omission of radiotherapy as an interesting alternative in the very favourable subcategories, especially for partial breast techniques. Although comparison of CC and CEA is hampered by the variability in clinical and economic settings, HEE-based evidence can guide decision-making to tailor-made strategies, allocating the optimal treatment in terms of effectiveness as well as efficiency to the right indication.