Alternate day treatment and late effects: the concept of an effective dose per fraction

Comparison of charges related to radiotherapy for soft-tissue sarcomas treated by preoperative external-beam irradiation versus interstitial implantation

BACKGROUND

We compared treatment-related charges associated with external beam irradiation and interstitial implantation for soft-tissue sarcoma of the extremity.

METHODS

Charges related to radiotherapy in 35 patients with soft-tissue sarcoma of the extremity were reviewed. Preoperative external beam irradiation (EB) delivering 50 Gy in 25 fractions with 6 MV photons was administered to 12 of the patients evaluated. The remaining 23 patients were treated with interstitial implantation (IR) as the only radiotherapeutic intervention. The anatomic distribution of the sarcomas treated by IR included 14 lower-extremity (LE) and nine upper-extremity (UE) lesions. The average length of iridium wire used for IR was 78 cm. Because LE lesions tend to be larger, the average length equaled 109.5 cm as compared with the 47 cm for UE implants.

RESULTS

The radiotherapeutic approach represented the only difference in treatment-related charges because the operative procedure of wide local excision was performed in each group. No difference in perioperative complications was observed between the two treatment approaches. Charges were stratified according to hospital-based and professional services. Radiotherapy-based hospital charges for the administration of EB averaged $6,515 compared with $4,050 for IR (p < 0.0001). Professional services also were significantly different, totaling $4,390 for EB and $3,240 for IR (p < 0.0001). The total of these charges for radiotherapy procedures and professional fees equaled $10,905 for EB compared with $7,290 for IR (p < 0.0001). Incorporating the necessary operating-room time for implant placement ($750) and five additional hospital days ($1,800), the costs associated with IR totaled $9,840; using chi-square analysis, the cost for IR remained significantly (p < 0.0001) less expensive than the $10,905 associated with EB. Because a large component of the radiotherapy cost for IR is related to the length of iridium 192 wire required, charges were stratified according to the location of the tumor. The total charge for IR of the UE equaled $9,345 compared with $10,335 for LE implants. Chi-square comparison for both UE and LE implants continued to show significant differences (p < 0.0001) when related to EB therapy.

CONCLUSION

Cost-analysis comparison of brachytherapy versus external beam irradiation found lower charges for patients undergoing adjuvant irradiation with brachytherapy for soft-tissue sarcoma. To optimize the cost-benefit ratio, prospective studies are necessary to define the application of these radiotherapeutic approaches based on clinical criteria.

Reflections on radiotherapy in Vietnam: political lessons still to be learned

Radiotherapy in Vietnam represents a stark contrast to the level of care available in the United States. The issue of efficient administration of cancer care with available resources is common to both nations. The challenge for each country is to develop treatment strategies and political policies for effective and accessible care within budgetary constraints. Results of therapy, defined as the restoration of function, must be the measure of efficacy and efficiency. This demands a balance between control of tumor-related symptoms and treatment-related morbidity. The most inefficient use of resources is an ineffective treatment that results in complications, as we observed in Vietnam. As health care policies continue to develop in the United States, we must not fail to focus upon therapeutic outcome as the single most important parameter for measuring success relative to the personal and public investment in medicine.