1
|
Eisavi M, Rezapour A, Alipour V, Mirzaei HR, Arabloo J. Cost-effectiveness analysis of intraoperative radiation therapy versus external beam radiation therapy for the adjuvant treatment of early breast cancer: A systematic review. Med J Islam Repub Iran 2020; 34:167. [PMID: 33816366 PMCID: PMC8004571 DOI: 10.47176/mjiri.34.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Indexed: 11/21/2022] Open
Abstract
Background: Breast-conserving surgery (BCS) is the recommended treatment for early breast cancer. After BCS. Whole-breast external beam radiotherapy (WB-EBRT) is the standard of care. A possible alternative to post-operative WB-EBRT is intraoperative radiation therapy (IORT). The objectives of this systematic review were to analyses the cost-effectiveness of IORT versus EBRT for early-stage breast cancer and to assess the reporting quality of the included studies to inform future studies.
Methods: A systematic literature search was carried out in five main databases (PubMed, Scopus, Embase, Cochrane library, and Web of Science) to identify original studies published to June 25, 2020. We included all full economic evaluation studies (cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and cost-benefit analysis (CBA), Model-based or trial-based) that assessed and compared IORT and EBRT in patients with early operable breast cancer. Study outcomes included cost per life-years gained or cost per quality-adjusted life-years (QALYs) gained or in monetary units or incremental cost-effectiveness ratio (ICER). The quality of the included articles was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. This review has been conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
Results: Of 1155 studies identified, eight studies met the inclusion criteria. In four studies, IORT was associated with lower costs and higher effectiveness than EBRT. In three studies, the dominant option was EBRT. In these studies, IORT also had lower costs and lower effectiveness than EBRT. Existing evidence suggests that IORT can be a cost-effective alternative to early breast cancer treatment by reducing therapeutic costs. Variables of cost-effectiveness were treatment costs, health state utilities, local and distant recurrence rates, and the probabilities of metastasis after treatment, recurrent cancer and death for both IORT and EBRT. The reporting quality of the included studies was "high" in five, "medium quality" in one and "low" in two studies.
Conclusion: Current evidence is sparse, and the number of studies was small but this evidence proposes that IORT can be a potential cost-saving strategy to the health systems for the adjuvant treatment of early breast cancer if the technology was carried out routinely in eligible patients. However, these results should be interpreted with caution because of the heterogeneity of studies and possible publication bias.
Collapse
Affiliation(s)
- Mahmoud Eisavi
- Faculty of Economics, Allameh Tabataba'i University, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Vahid Alipour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Mirzaei
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jalal Arabloo
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
2
|
Vaidya A, Vaidya P, Both B, Brew-Graves C, Bulsara M, Vaidya JS. Health economics of targeted intraoperative radiotherapy (TARGIT-IORT) for early breast cancer: a cost-effectiveness analysis in the United Kingdom. BMJ Open 2017; 7:e014944. [PMID: 28819067 PMCID: PMC5724101 DOI: 10.1136/bmjopen-2016-014944] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/20/2017] [Accepted: 05/09/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The clinical effectiveness of targeted intraoperative radiotherapy (TARGIT-IORT) has been confirmed in the randomised TARGIT-A (targeted intraoperative radiotherapy-alone) trial to be similar to a several weeks' course of whole-breast external-beam radiation therapy (EBRT) in patients with early breast cancer. This study aims to determine the cost-effectiveness of TARGIT-IORT to inform policy decisions about its wider implementation. SETTING TARGIT-A randomised clinical trial (ISRCTN34086741) which compared TARGIT with traditional EBRT and found similar breast cancer control, particularly when TARGIT was given simultaneously with lumpectomy. METHODS Cost-utility analysis using decision analytic modelling by a Markov model. A cost-effectiveness Markov model was developed using TreeAge Pro V.2015. The decision analytic model compared two strategies of radiotherapy for breast cancer in a hypothetical cohort of patients with early breast cancer based on the published health state transition probability data from the TARGIT-A trial. Analysis was performed for UK setting and National Health Service (NHS) healthcare payer's perspective using NHS cost data and treatment outcomes were simulated for both strategies for a time horizon of 10 years. Model health state utilities were drawn from the published literature. Future costs and effects were discounted at the rate of 3.5%. To address uncertainty, one-way and probabilistic sensitivity analyses were performed. MAIN OUTCOME MEASURES Quality-adjusted life-years (QALYs). RESULTS In the base case analysis, TARGIT-IORT was a highly cost-effective strategy yielding health gain at a lower cost than its comparator EBRT. Discounted TARGIT-IORT and EBRT costs for the time horizon of 10 years were £12 455 and £13 280, respectively. TARGIT-IORT gained 0.18 incremental QALY as the discounted QALYs gained by TARGIT-IORT were 8.15 and by EBRT were 7.97 showing TARGIT-IORT as a dominant strategy over EBRT. Model outputs were robust to one-way and probabilistic sensitivity analyses. CONCLUSIONS TARGIT-IORT is a dominant strategy over EBRT, being less costly and producing higher QALY gain. TRIAL REGISTRATION NUMBER ISRCTN34086741; post results.
Collapse
Affiliation(s)
- Anil Vaidya
- School of Public Health, University of Alberta, Edmonton, Canada
- O-ZONE 2.0 Inc. HEOR Consultancy, Edmonton, Canada
| | - Param Vaidya
- O-ZONE 2.0 Inc. HEOR Consultancy, Edmonton, Canada
| | - Brigitte Both
- Carl-Zeiss Meditec AG, Oberkochen, Germany
- Witten/Herdecke University, Herdecke, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Australia
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK
| |
Collapse
|
3
|
Hosseini A, Khoury AL, Esserman LJ. Precision surgery and avoiding over-treatment. Eur J Surg Oncol 2017; 43:938-943. [PMID: 28238520 DOI: 10.1016/j.ejso.2017.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 02/04/2017] [Indexed: 10/20/2022] Open
Abstract
Over-diagnosis and over-treatment are consequences of greater awareness about breast cancer, more intensive screening, and the resultant identification of more cases of breast cancer that are low or ultralow risk. This area represents an important opportunity to optimize the delivery of appropriate targeted therapy for breast cancer patients. Despite the evolution of breast cancer care over the last few decades and our ability to tailor treatment to biology, a one-size fits all approach is still prevalent in the local and regional management of and screening for breast cancer, failing to reflect the unique biology and tumor characteristics of each patient. In this review, we explore how we can use new tools to better define tumor biology and also how we can change current clinical practices based on already available data. Every surgeon should be knowledgeable about how to craft personalized breast cancer care in the areas of systemic therapy, adjuvant radiation therapy, management of ductal carcinoma in situ (DCIS), precision surgery, and breast cancer screening.
Collapse
Affiliation(s)
- A Hosseini
- University of California, 1600 Divisadero, 2nd Floor Box 1710, San Francisco, CA 94115, USA.
| | - A L Khoury
- University of California, 1600 Divisadero, 2nd Floor Box 1710, San Francisco, CA 94115, USA.
| | - L J Esserman
- University of California, 1600 Divisadero, 2nd Floor Box 1710, San Francisco, CA 94115, USA.
| |
Collapse
|
4
|
Piotrowski I, Kulcenty K, Wichtowski M, Murawa D, Suchorska W. Intraoperative Radiotherapy of Breast Cancer and Its Biological Effects. Breast Care (Basel) 2017; 12:109-113. [PMID: 28559768 DOI: 10.1159/000454673] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Conservative breast cancer surgery followed by radiation therapy is the standard treatment for this type of cancer. Numerous studies demonstrate that 90% of local recurrences after traditional surgery occur in the same quadrant as the primary cancer. The published data suggest that the wound healing process after surgery alters the area surrounding the original tumor and the modified microenvironment is more favorable for the tumor to recur. The majority of metastases within scar initiated much research, and the consequences of these studies led to clinical trials aimed at assessing whether localized radiotherapy, such as intraoperative radiotherapy (IORT), would be more effective in inhibiting formation of local recurrence than the standard postoperative whole breast radiotherapy. IORT involves irradiation of diseased tissue directly during surgery. The rationale for this approach is the fact that the increase in the radiation dose increases local tumor control, which is the primary goal of radiation therapy. The biological basis of this process are still not thoroughly understood. Gaining new knowledge about the recurrence formation at the molecular level could serve as a starting point for further analysis and to create an opportunity to identify new targets of therapy, and possibly new therapeutic agents.
Collapse
Affiliation(s)
- Igor Piotrowski
- Radiobiology Laboratory, Department of Medical Physics, Greater Poland Cancer Centre, Pozna'n, Poland.,Department of Electroradiology, University of Medical Sciences, Pozna'n, Poland
| | - Katarzyna Kulcenty
- Radiobiology Laboratory, Department of Medical Physics, Greater Poland Cancer Centre, Pozna'n, Poland.,Department of Electroradiology, University of Medical Sciences, Pozna'n, Poland
| | - Mateusz Wichtowski
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Pozna'n, Poland
| | - Dawid Murawa
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Pozna'n, Poland
| | - Wiktoria Suchorska
- Radiobiology Laboratory, Department of Medical Physics, Greater Poland Cancer Centre, Pozna'n, Poland.,Department of Electroradiology, University of Medical Sciences, Pozna'n, Poland
| |
Collapse
|
5
|
Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Saunders C, Brew-Graves C, Potyka I, Morris S, Vaidya HJ, Williams NR, Baum M. An international randomised controlled trial to compare TARGeted Intraoperative radioTherapy (TARGIT) with conventional postoperative radiotherapy after breast-conserving surgery for women with early-stage breast cancer (the TARGIT-A trial). Health Technol Assess 2016; 20:1-188. [PMID: 27689969 DOI: 10.3310/hta20730] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Based on our laboratory work and clinical trials we hypothesised that radiotherapy after lumpectomy for breast cancer could be restricted to the tumour bed. In collaboration with the industry we developed a new radiotherapy device and a new surgical operation for delivering single-dose radiation to the tumour bed - the tissues at highest risk of local recurrence. We named it TARGeted Intraoperative radioTherapy (TARGIT). From 1998 we confirmed its feasibility and safety in pilot studies. OBJECTIVE To compare TARGIT within a risk-adapted approach with whole-breast external beam radiotherapy (EBRT) over several weeks. DESIGN The TARGeted Intraoperative radioTherapy Alone (TARGIT-A) trial was a pragmatic, prospective, international, multicentre, non-inferiority, non-blinded, randomised (1 : 1 ratio) clinical trial. Originally, randomisation occurred before initial lumpectomy (prepathology) and, if allocated TARGIT, the patient received it during the lumpectomy. Subsequently, the postpathology stratum was added in which randomisation occurred after initial lumpectomy, allowing potentially easier logistics and a more stringent case selection, but which needed a reoperation to reopen the wound to give TARGIT as a delayed procedure. The risk-adapted approach meant that, in the experimental arm, if pre-specified unsuspected adverse factors were found postoperatively after receiving TARGIT, EBRT was recommended. Pragmatically, this reflected how TARGIT would be practised in the real world. SETTING Thirty-three centres in 11 countries. PARTICIPANTS Women who were aged ≥ 45 years with unifocal invasive ductal carcinoma preferably ≤ 3.5 cm in size. INTERVENTIONS TARGIT within a risk-adapted approach and whole-breast EBRT. MAIN OUTCOME MEASURES The primary outcome measure was absolute difference in local recurrence, with a non-inferiority margin of 2.5%. Secondary outcome measures included toxicity and breast cancer-specific and non-breast-cancer mortality. RESULTS In total, 3451 patients were recruited between March 2000 and June 2012. The following values are 5-year Kaplan-Meier rates for TARGIT compared with EBRT. There was no statistically significant difference in local recurrence between TARGIT and EBRT. TARGIT was non-inferior to EBRT overall [TARGIT 3.3%, 95% confidence interval (CI) 2.1% to 5.1% vs. EBRT 1.3%, 95% CI 0.7% to 2.5%; p = 0.04; Pnon-inferiority = 0.00000012] and in the prepathology stratum (n = 2298) when TARGIT was given concurrently with lumpectomy (TARGIT 2.1%, 95% CI 1.1% to 4.2% vs. EBRT 1.1%, 95% CI 0.5% to 2.5%; p = 0.31; Pnon-inferiority = 0.0000000013). With delayed TARGIT postpathology (n = 1153), the between-group difference was larger than 2.5% and non-inferiority was not established for this stratum (TARGIT 5.4%, 95% CI 3.0% to 9.7% vs. EBRT 1.7%, 95% CI 0.6% to 4.9%; p = 0.069; Pnon-inferiority = 0.06640]. The local recurrence-free survival was 93.9% (95% CI 90.9% to 95.9%) when TARGIT was given with lumpectomy compared with 92.5% (95% CI 89.7% to 94.6%) for EBRT (p = 0.35). In a planned subgroup analysis, progesterone receptor (PgR) status was found to be the only predictor of outcome: hormone-responsive patients (PgR positive) had similar 5-year local recurrence with TARGIT during lumpectomy (1.4%, 95% CI 0.5% to 3.9%) as with EBRT (1.2%, 95% CI 0.5% to 2.9%; p = 0.77). Grade 3 or 4 radiotherapy toxicity was significantly reduced with TARGIT. Overall, breast cancer mortality was much the same between groups (TARGIT 2.6%, 95% CI 1.5% to 4.3% vs. EBRT 1.9%, 95% CI 1.1% to 3.2%; p = 0.56) but there were significantly fewer non-breast-cancer deaths with TARGIT (1.4%, 95% CI 0.8% to 2.5% vs. 3.5%, 95% CI 2.3% to 5.2%; p = 0.0086), attributable to fewer deaths from cardiovascular causes and other cancers, leading to a trend in reduced overall mortality in the TARGIT arm (3.9%, 95% CI 2.7% to 5.8% vs. 5.3%, 95% CI 3.9% to 7.3%; p = 0.099]. Health economic analyses suggest that TARGIT was statistically significantly less costly than EBRT, produced similar quality-adjusted life-years, had a positive incremental net monetary benefit that was borderline statistically significantly different from zero and had a probability of > 90% of being cost-effective. There appears to be little uncertainty in the point estimates, based on deterministic and probabilistic sensitivity analyses. If TARGIT were given instead of EBRT in suitable patients, it might potentially reduce costs to the health-care providers in the UK by £8-9.1 million each year. This does not include environmental, patient and societal costs. LIMITATIONS The number of local recurrences is small but the number of events for local recurrence-free survival is not as small (TARGIT 57 vs. EBRT 59); occurrence of so few events (< 3.5%) also implies that both treatments are effective and any difference is unlikely to be large. Not all 3451 patients were followed up for 5 years; however, more than the number of patients required to answer the main trial question (n = 585) were followed up for > 5 years. CONCLUSIONS For patients with breast cancer (women who are aged ≥ 45 years with hormone-sensitive invasive ductal carcinoma that is up to 3.5 cm in size), TARGIT concurrent with lumpectomy within a risk-adapted approach is as effective as, safer than and less expensive than postoperative EBRT. FUTURE WORK The analyses will be repeated with longer follow-up. Although this may not change the primary result, the larger number of events may confirm the effect on overall mortality and allow more detailed subgroup analyses. The TARGeted Intraoperative radioTherapy Boost (TARGIT-B) trial is testing whether or not a tumour bed boost given intraoperatively (TARGIT) boost is superior to a tumour bed boost given as part of postoperative EBRT. TRIAL REGISTRATION Current Controlled Trials ISRCTN34086741 and ClinicalTrials.gov NCT00983684. FUNDING University College London Hospitals (UCLH)/University College London (UCL) Comprehensive Biomedical Research Centre, UCLH Charities, Ninewells Cancer Campaign, National Health and Medical Research Council and German Federal Ministry of Education and Research (BMBF). From September 2009 this project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 73. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Surgery, Whittington Hospital, Royal Free Hospital and University College London Hospital, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Christobel Saunders
- Department of Surgery, University of Western Australia, Perth, WA, Australia
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Stephen Morris
- Health Economics Group, Department of Biomedical Engineering, University College London, London, UK
| | | | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
| |
Collapse
|
6
|
Picot J, Copley V, Colquitt JL, Kalita N, Hartwell D, Bryant J. The INTRABEAM® Photon Radiotherapy System for the adjuvant treatment of early breast cancer: a systematic review and economic evaluation. Health Technol Assess 2016; 19:1-190. [PMID: 26323045 DOI: 10.3310/hta19690] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Initial treatment for early breast cancer is usually either breast-conserving surgery (BCS) or mastectomy. After BCS, whole-breast external beam radiotherapy (WB-EBRT) is the standard of care. A potential alternative to post-operative WB-EBRT is intraoperative radiation therapy delivered by the INTRABEAM(®) Photon Radiotherapy System (Carl Zeiss, Oberkochen, Germany) to the tissue adjacent to the resection cavity at the time of surgery. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of INTRABEAM for the adjuvant treatment of early breast cancer during surgical removal of the tumour. DATA SOURCES Electronic bibliographic databases, including MEDLINE, EMBASE and The Cochrane Library, were searched from inception to March 2014 for English-language articles. Bibliographies of articles, systematic reviews, clinical guidelines and the manufacturer's submission were also searched. The advisory group was contacted to identify additional evidence. METHODS Systematic reviews of clinical effectiveness, health-related quality of life and cost-effectiveness were conducted. Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to full texts of retrieved papers by one reviewer and checked by a second reviewer. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer, and differences in opinion were resolved through discussion at each stage. Clinical effectiveness studies were included if they were carried out in patients with early operable breast cancer. The intervention was the INTRABEAM system, which was compared with WB-EBRT, and study designs were randomised controlled trials (RCTs). Controlled clinical trials could be considered if data from available RCTs were incomplete (e.g. absence of data on outcomes of interest). A cost-utility decision-analytic model was developed to estimate the costs, benefits and cost-effectiveness of INTRABEAM compared with WB-EBRT for early operable breast cancer. RESULTS One non-inferiority RCT, TARGeted Intraoperative radioTherapy Alone (TARGIT-A), met the inclusion criteria for the review. The review found that local recurrence was slightly higher following INTRABEAM than WB-EBRT, but the difference did not exceed the 2.5% non-inferiority margin providing INTRABEAM was given at the same time as BCS. Overall survival was similar with both treatments. Statistically significant differences in complications were found for the occurrence of wound seroma requiring more than three aspirations (more frequent in the INTRABEAM group) and for a Radiation Therapy Oncology Group toxicity score of grade 3 or 4 (less frequent in the INTRABEAM group). Cost-effectiveness base-case analysis indicates that INTRABEAM is less expensive but also less effective than WB-EBRT because it is associated with lower total costs but fewer total quality-adjusted life-years gained. However, sensitivity analyses identified four model parameters that can cause a switch in the treatment option that is considered cost-effective. LIMITATIONS The base-case result from the model is subject to uncertainty because the disease progression parameters are largely drawn from the single available RCT. The RCT median follow-up of 2 years 5 months may be inadequate, particularly as the number of participants with local recurrence is low. The model is particularly sensitive to this parameter. CONCLUSIONS AND IMPLICATIONS A significant investment in INTRABEAM equipment and staff training (clinical and non-clinical) would be required to make this technology available across the NHS. Longer-term follow-up data from the TARGIT-A trial and analysis of registry data are required as results are currently based on a small number of events and economic modelling results are uncertain. STUDY REGISTRATION This study is registered as PROSPERO CRD42013006720. FUNDING The National Institute for Health Research Health Technology Assessment programme. Note that the economic model associated with this document is protected by intellectual property rights, which are owned by the University of Southampton. Anyone wishing to modify, adapt, translate, reverse engineer, decompile, dismantle or create derivative work based on the economic model must first seek the agreement of the property owners.
Collapse
Affiliation(s)
- Jo Picot
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Vicky Copley
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jill L Colquitt
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Neelam Kalita
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Debbie Hartwell
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jackie Bryant
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| |
Collapse
|
7
|
Esserman L, Gallant E, Alvarado M. Less Is More: The Evolving Surgical Approach to Breast Cancer. Am Soc Clin Oncol Educ Book 2016; 35:e5-e10. [PMID: 27249759 DOI: 10.1200/edbk_159060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Personalized medicine is emerging as an important guiding principle in diagnosis and treatment. This means not just doing more for some, but safely doing less for others. The lessons learned about the biology of breast cancer over the last 2 decades have enabled us to understand the incredible heterogeneity of breast cancer and its associated behavior. Although much work remains, there is an emerging opportunity to identify and recognize more indolent forms of breast cancer, made more prevalent through the widespread adoption of screening. With our improving systemic therapies and improved molecular tools, we now have the opportunity to reduce the burden of treatment in women with lower-risk tumors. Our surgical treatments have evolved, with less morbid and more cosmetic procedures. In this article, we review the indications for further reducing local therapy, including adjuvant radiation.
Collapse
Affiliation(s)
- Laura Esserman
- From the University of California, San Francisco, San Francisco, CA
| | - Etienne Gallant
- From the University of California, San Francisco, San Francisco, CA
| | - Michael Alvarado
- From the University of California, San Francisco, San Francisco, CA
| |
Collapse
|
8
|
Najafipour F, Hamouzadeh P, Arabloo J, Mobinizadeh M, Norouzi A. Safety, effectiveness and economic evaluation of intra-operative radiation therapy: a systematic review. Med J Islam Repub Iran 2015; 29:258. [PMID: 26793649 PMCID: PMC4715414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 02/22/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Intra-operative radiation therapy (IORT) is the transfer of a single large radiation dose to the tumor bed during surgery with the final goal of improving regional tumor control. This study aimed to investigate the safety, effectiveness and economic evaluation of intra-operative radiation therapy. METHODS The scientific literature was searched in the main biomedical databases (Centre for Reviews and Dissemination, Cochrane Library and PubMed) up to March 2014. Two independent reviewers selected the papers based on pre-established inclusion criteria, with any disagreements being resolved by consensus. Data were then extracted and summarized in a structured form. RESULTS from studies were analyzed and discussed within a descriptive synthesis. RESULTS Sixteen studies met the inclusion criteria. It seems that outcomes from using intraoperative radiation therapy can be considered in various kinds of cancers like breast, pancreatic and colorectal cancers. The application of this method may provide significant survival increase only for colorectal cancer, but this increase was not significant for other types of cancer. This technology had low complications; and it is relatively safe. Using intra-operative radiation therapy could potentially be accounted as a cost-effective strategy for controlling and managing breast cancer. CONCLUSION According to the existing evidences, that are the highest medical evidences for using intra-operative radiation therapy, one can generally conclude that intra-operative radiation therapy is considered as a relatively safe and cost-effective method for managing early-stage breast cancer and it can significantly increase the survival of patients with colorectal cancer. Also, the results of this study have policy implications with respect to the reimbursement of this technology.
Collapse
Affiliation(s)
- Farshad Najafipour
- 1 Department of Epidemiology, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran.
| | - Pejman Hamouzadeh
- 2 Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Jalal Arabloo
- 3 Health Management and Economics Research Center, Iran University of Medical Sciences & Dept. of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammadreza Mobinizadeh
- 4 Young Researches and Elites Club, Science and Research Branch, Islamic Azad University, Tehran, Iran.
| | - Amir Norouzi
- 5 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran. ,(Corresponding author) Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
9
|
Vaidya JS, Bulsara M, Wenz F, Joseph D, Saunders C, Massarut S, Flyger H, Eiermann W, Alvarado M, Esserman L, Falzon M, Brew-Graves C, Potyka I, Tobias JS, Baum M. Pride, Prejudice, or Science: Attitudes Towards the Results of the TARGIT-A Trial of Targeted Intraoperative Radiation Therapy for Breast Cancer. Int J Radiat Oncol Biol Phys 2015; 92:491-7. [PMID: 26068479 PMCID: PMC4464618 DOI: 10.1016/j.ijrobp.2015.03.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 03/04/2015] [Accepted: 03/19/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Jayant S Vaidya
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK; Department of Surgery, Royal Free Hospital, London, UK; Department of Surgery, Whittington Health, London, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Christobel Saunders
- Department of Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Surgery, University of Western Australia, Perth, WA, Australia
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologia, Aviano, Italy
| | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, California
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, California
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, UK
| | - Chris Brew-Graves
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - Michael Baum
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | | |
Collapse
|
10
|
Intraoperative Radiotherapy: Is it Ready for Prime Time? CURRENT BREAST CANCER REPORTS 2015. [DOI: 10.1007/s12609-014-0174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
11
|
Haste makes waste, but lack of urgency is opportunity lost. Breast Cancer Res Treat 2014; 147:223-4. [DOI: 10.1007/s10549-014-3036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
12
|
Wang F, Peled AW, Garwood E, Fiscalini AS, Sbitany H, Foster RD, Alvarado M, Ewing C, Hwang ES, Esserman LJ. Total Skin-Sparing Mastectomy and Immediate Breast Reconstruction: An Evolution of Technique and Assessment of Outcomes. Ann Surg Oncol 2014; 21:3223-30. [DOI: 10.1245/s10434-014-3915-z] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Indexed: 11/18/2022]
|
13
|
Kaidar-Person O, Poortmans P, Klimberg S, Haviland J, Offersen B, Audisio R, Yarnold J. Haste makes waste: are the data regarding TARGIT-A IORT ready for prime time? Breast Cancer Res Treat 2014; 147:221-2. [PMID: 25048466 DOI: 10.1007/s10549-014-3032-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 06/09/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Orit Kaidar-Person
- Division of Oncology, Rambam Health Care Campus, POB 9602, 31096, Haifa, Israel,
| | | | | | | | | | | | | |
Collapse
|