Economic Evaluation of Surgery Alone versus Surgery Plus Adjuvant Therapy for Glioblastomas in India

Glioblastoma multiforme (GBM) continues to have a poor prognosis despite advances in therapeutic modalities. Given the rising costs of treatment, it is unclear how cost-effective treating the condition is in a middle-income country.

To compare the cost-effectiveness (CE) of different strategies for treating GBMs in India.

Seventy adult patients with GBMs were included in this analysis. Direct and indirect costs were calculated from a societal perspective. Effectiveness was calculated in terms of quality-adjusted life years (QALYs). A decision-tree model compared different real-world strategies: surgery (maximal safe resection) alone, surgery with radiotherapy (RT) and concurrent temozolomide (RT-TMZ), and surgery with RT-TMZ and adjuvant TMZ (Stupp protocol). These were compared with a hypothetical "no active treatment" group. Incremental CE ratios (ICERs) were calculated, and a one-way sensitivity analysis was performed.

Using a CE threshold of 1 per-capita gross domestic product (INR 2,28,007)/QALY, surgery alone was found to be cost-effective (ICER of INR 61,790/QALY compared to "no active treatment"), while the Stupp protocol was not (ICER of INR 12,06,595/QALY compared to surgery). Sensitivity analysis revealed that the ICERs were most sensitive to the duration and utility of progression-free survival (PFS), loss of productivity, and cost of intervention.

Surgery without adjuvant therapy is currently the only cost-effective treatment strategy for GBMs in India. In order to provide a cost-effective Stupp protocol, health policymakers should address the high costs of adjuvant RT, invest in methods for screening and early diagnosis to improve PFS, and develop policies to improve disease-related QOL and productivity.