The cost-effectiveness and cost-utility of high-dose palliative radiotherapy for advanced non-small-cell lung cancer

The experience of providing hospice care concurrent with cancer treatment in the VA

PURPOSE

Veterans with advanced cancer can receive hospice care concurrently with treatments such as radiation and chemotherapy. However, variations exist in concurrent care use across Veterans Affairs (VA) medical centers (VAMCs), and overall, concurrent care use is relatively rare. In this qualitative study, we aimed to identify, describe, and explain factors that influence the provision of concurrent cancer care (defined as chemotherapy or radiation treatments provided with hospice) for veterans with terminal cancer.

METHODS

From August 2015 to April 2016, we conducted six site visits and interviewed 76 clinicians and staff at six VA sites and their contracted community hospices, including community hospices (n = 16); VA oncology (n = 25); VA palliative care (n = 17); and VA inpatient hospice and palliative care units (n = 18).

RESULTS

Thematic qualitative content analysis found three themes that influenced the provision of concurrent care: (1) clinicians and staff at community hospices and at VAs viewed concurrent care as a viable care option, as it preserved hope and relationships while patient goals are clarified during transitions to hospice; and (2) the presence of dedicated liaisons facilitated care coordination and education about concurrent care; however, (3) clinicians and staff concerns about Medicare guideline compliance hindered use of concurrent care.

CONCLUSIONS

While concurrent care is used by a small number of veterans with advanced cancer, VA staff valued having the option available and as a bridge to hospice. Hospice staff felt concurrent care improved care coordination with VAMCs, but use may be tempered due to concerns related to Medicare compliance.

The use of Quality-Adjusted Life Years in cost-effectiveness analyses in palliative care: Mapping the debate through an integrative review

BACKGROUND

In cost-effectiveness analyses in healthcare, Quality-Adjusted Life Years are often used as outcome measure of effectiveness. However, there is an ongoing debate concerning the appropriateness of its use for decision-making in palliative care.

AIM

To systematically map pros and cons of using the Quality-Adjusted Life Year to inform decisions on resource allocation among palliative care interventions, as brought forward in the debate, and to discuss the Quality-Adjusted Life Year's value for palliative care.

DESIGN

The integrative review method of Whittemore and Knafl was followed. Theoretical arguments and empirical findings were mapped.

DATA SOURCES

A literature search was conducted in PubMed, EMBASE, and CINAHL, in which MeSH (Medical Subject Headings) terms were Palliative Care, Cost-Benefit Analysis, Quality of Life, and Quality-Adjusted Life Years.

FINDINGS

Three themes regarding the pros and cons were identified: (1) restrictions in life years gained, (2) conceptualization of quality of life and its measurement, including suggestions to adapt this, and (3) valuation and additivity of time, referring to changing valuation of time. The debate is recognized in empirical studies, but alternatives not yet applied.

CONCLUSION

The Quality-Adjusted Life Year might be more valuable for palliative care if specific issues are taken into account. Despite restrictions in life years gained, Quality-Adjusted Life Years can be achieved in palliative care. However, in measuring quality of life, we recommend to-in addition to the EQ-5D- make use of quality of life or capability instruments specifically for palliative care. Also, we suggest exploring the possibility of integrating valuation of time in a non-linear way in the Quality-Adjusted Life Year.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

Variation in the use of palliative radiotherapy at end of life: examining demographic, clinical, health service, and geographic factors in a population-based study

Palliative radiotherapy (PRT) can improve quality of life for people dying of cancer. Variation in the delivery of PRT by factors unrelated to need may indicate that not all patients who may benefit from PRT receive it. In this study, 13,494 adults who died of cancer between 2000 and 2005 in Nova Scotia, Canada, were linked to radiotherapy records. Multivariate logistic regression was used to examine the relationships among demographic, clinical, service, and geographic variables, and PRT consultation and treatment. Among the decedents, 4188 (31.0%) received PRT consultation and 3032 (22.3%) treatment. PRT declined with increased travel time and community deprivation. Females, older persons, and nursing home residents also had lower PRT rates. Variations were observed by cancer site and previous oncology care. Variations in PRT use should be discussed with referring physicians, and improved means of access to PRT considered. Benchmarks for optimal rates of PRT are needed.

Cost-effectiveness studies in radiation therapy

The field of radiation therapy has made dramatic technical advances over the past 20 years. 3D conformal radiotherapy, intensity-modulated radiation therapy and proton beam therapy have all been developed in an attempt to improve the therapeutic ratio: higher cure rates with lower toxicity. Unfortunately, although the costs of radiation therapy are certainly increasing, it is unclear whether its clinical benefit has also improved. Cost-effectiveness analyses are designed to formally evaluate the cost of a treatment relative to an associated change in quality-adjusted survival. As the cost of oncologic care is increasing, it is critically important to assess the cost-effectiveness of radiation therapy. This article will describe the issues surrounding the delivery and cost of radiation therapy, and it will summarize the work that has been done to evaluate the use of cost-effectiveness in radiation oncology.

The cost of lung cancer in Alberta

BACKGROUND

Lung cancer is the leading cause of cancer morbidity and mortality. In addition, lung cancer has a significant economic impact on society.

OBJECTIVE

To present an economic analysis of the actual care costs of lung cancer which will allow comparison with, and verification of, cost estimates that were developed through modelling and opinion.

METHODS

A chart review was conducted of incident cases (circa 1998) of primary bronchogenic lung cancer. Cases were censored at two years from the date of diagnosis. Relevant clinical and health utilization data were collected. Health utilization data included hospital and institutional outpatient (ie, ambulatory clinic) costs. Cost estimates were derived for over 200 specific health services. The present analysis was performed from the economic perspective of the health care institution.

RESULTS

A total of 13,389 health service events were captured with an estimated total cost of $8.4 million. Laboratory tests, diagnostic imaging and ambulatory visits constituted 86% of the service events while patient admissions and therapy constituted 76% of the costs. The vast majority of overall costs occurred just before, or within, three months of diagnosis. The median nonsmall cell lung cancer and small cell lung cancer case costs were $10,928 (range $9,234 to $11,047) and $15,350 (range $13,033 to $21,436), respectively.

CONCLUSION

The results agree with the literature that the majority of lung cancer case costs are realized around the date of diagnosis (ie, early phase). The present study illustrates Canadian health care system lung cancer case costs based on actual care received versus hypothetical care algorithms.

Long-term prognostic value of 18F-FDG PET in patients with locally advanced rectal cancer previously treated with neoadjuvant radiochemotherapy

OBJECTIVE

The purpose of this study was to assess the prognostic value of (18)F-FDG PET performed at restaging in patients with locally advanced rectal cancer who previously underwent neoadjuvant radiochemotherapy.

SUBJECTS AND METHODS

Eighty-eight patients with histologically proven rectal cancer classified at clinical TNM stages II and III were enrolled. Six weeks after radiochemotherapy completion, all patients were restaged by sonography, CT, MRI, endoscopy, and (18)F-FDG PET. Surgery was performed in all patients within 8-9 weeks from completion of radiochemotherapy. Median follow-up after surgery was 38 months (range, 6-66 months).

RESULTS

The 5-year overall survival and disease-free survival were 83% and 73%, respectively. Cox multivariate analysis showed that only two parameters at restaging were independent prognostic predictors of both overall survival and disease-free survival: pathologic stage and, especially, after radiochemotherapy (18)F-FDG PET findings. The 5-year overall survival was 91% in patients with a negative PET after radiochemotherapy versus 72% in those with a positive PET (p = 0.024) after radiochemotherapy, whereas disease-free survival was 81% and 62% (p = 0.003) for those with the negative and positive PET findings, respectively. Statistical data were further enhanced when combining the pathologic stage with the (18)F-FDG PET results: 95% 5-year overall survival in the PET-negative pathologic stages 0 and I patients versus 70% in PET-positive pathologic stages II-IV patients (p = 0.001), whereas disease-free survival was 93% and 65% (p = 0.0003) for the negative and positive PETs, respectively.

CONCLUSION

In patients with locally advanced rectal cancer previously treated with neoadjuvant radiochemotherapy, the combined evaluation of pathologic stage and after-radiochemotherapy (18)F-FDG PET at restaging identified a subgroup of patients characterized by good response to radiochemotherapy and a more favorable prognosis. In these patients, a conservative surgical approach might be considered.

Considerations of Cost-Effectiveness for New Radiation Oncology Technologies

PURPOSE

The additional equipment and personnel costs of supplying image-guided radiation therapy (IGRT) technology have caused many to question if the marginal gains in patients' health-related quality of life are worth the additional cost. Novel IGRT technologies, including cone-beam computed tomography and helical tomotherapy, provide the opportunity to study cost and effectiveness for patients.

MATERIALS AND METHODS

This methodologic study proposes to evaluate the cost and effectiveness of treating conventional radiotherapy versus IGRT patients prospectively among several institutions. The cost of treating patients varies among institutions depending on personnel, equipment, and overhead costs, but the nature and quality of services provided are expected to be consistent.

RESULTS

The study will track cost information at a single institution and simultaneously as the median from multiple institutions. Effectiveness measures will include both standard quality-adjusted life-year instruments completed by patients and performance status measures completed by institutional personnel. In addition, disease-specific effectiveness measures will be accommodated in the study. Each participating institution will use the same effectiveness measures to track patients with similar diseases.

CONCLUSION

The resulting cost and effectiveness data will be available to investigators at any point during the study, immediately on the completion of a trial, or when statistical acceptability is achieved. These considerations are being incorporated into a high-level information model under development.

Cost-effectiveness of routine mediastinoscopy in computed tomography– and positron emission tomography–screened patients with stage I lung cancer

OBJECTIVE

Accurate preoperative staging is essential for the optimal management of patients with lung cancer. An important goal of preoperative staging is to identify mediastinal lymph node metastasis. Computed tomography and positron emission tomography may identify mediastinal lymph node metastasis with sufficient sensitivity to allow omission of mediastinoscopy. This study utilizes our experience with patients with clinical stage I lung cancer to perform a decision analysis addressing whether mediastinoscopy should be performed in clinical stage I lung cancer patients staged by computed tomography and positron emission tomography.

METHODS

We retrospectively reviewed our thoracic surgery database for cases between May 1999 and May 2004. Patients deemed clinical stage I by computed tomography and positron emission tomography were chosen for further study. Individual computed tomography, positron emission tomography, and operative and pathology reports were reviewed. The postresection pathologic staging and long-term survival were recorded. A decision model was created using TreeAgePro software and our observed data for the prevalence of mediastinal lymph node metastases and for the rate of benign nodules. Data reported in the literature were also utilized to complete the decision analysis model. A sensitivity analysis of key variables was performed.

RESULTS

A total of 248 patients with clinical stage I lung tumors were identified. One hundred seventy-eight patients (72%) underwent mediastinoscopy before resection, and 5/178 (3%) showed N2 disease. An additional 9 patients were found to have N2 metastasis in the final resected specimen, resulting in a total of 14/248 patients (5.6%) with occult mediastinal lymph node metastases. Benign nodules were found in 19/248 (8%) of patients. Decision analysis determined that mediastinoscopy added 0.008 years of life expectancy at a cost of 250,989 dollars per life-year gained. The outcome was sensitive to the prevalence of N2 disease in the population and the benefit of induction versus adjuvant therapy for N2 lung cancer. If the prevalence of N2 disease exceeds 10%, the sensitivity analysis predicts that mediastinoscopy would lengthen life at a cost of less than 100,000 dollars per life-year gained.

CONCLUSION

Patients with clinical stage I lung cancer staged by computed tomography and positron emission tomography benefit little from mediastinoscopy. The survival advantage it confers is very small and is dependent on the prevalence of N2 metastasis and the unproven superiority of induction therapy over adjuvant therapy.

Évaluation économique de la radiothérapie : méthodes et résultats

The cost of radiotherapy, which concerns 150,000 new patients yearly in France has been estimated 1700 euros per patients in this country, 50% lower than the European average. Economic evaluations of radiotherapy have related the cost of either curative or palliative treatment to the medical outcome. For lung, rectal, breast cancer and bone metastases of prostate cancer, radiation therapy prolongs life by an estimated 6 to 10 months. The cost effectiveness ranges from 5,000 to 25,000 euros per life year gained.

CHART in lung cancer: Economic evaluation and incentives for implementation

BACKGROUND AND PURPOSE

To investigate the financial consequences and the impact on daily implementation of CHART in lung cancer.

PATIENTS AND METHODS

A cost-effectiveness and cost-utility analysis were performed using Markov models, comparing the early and delayed costs and effects of CHART for NSCLC over a 4-year time span from a societal viewpoint. The outcome estimates were based on the CHART literature, the cost estimates on the standard practice of the Leuven University Hospitals, the radiotherapy costs being derived from an activity-based costing (ABC) programme developed in the department.

RESULTS

The additional societal cost per life-year gained was 9164 Euro, the incremental cost per quality-adjusted life-year 11,576 Euro. Sensitivity analyses confirmed the robustness of these results, the incremental cost-utility ratio remaining well under 20,000 Euro/QALY in all tested circumstances. The threshold analyses found the results of the study to be sensitive to the cost of CHART and to the quality of life after treatment. More specifically, standard treatment would become the optimal treatment if CHART would have a higher cost or would result in more long-term side effects.

CONCLUSION

CHART should not be denied to patients with NSCLC on the basis of clinical or economic arguments. Other factors such as socio-economical, institutional, practical departmental and physician-bound barriers most probably explain the lack of implementation into daily practice.

Estimating the benefit and cost of radiotherapy for lung cancer

Purpose: To estimate the benefit and cost of using radiotherapy (RT) in the initial management of lung cancer in the general population.

Methods: We identified indications for RT in the initial management of small cell and non–small cell lung cancer through a review of the literature. The proportion of patients with each specific indication for treatment was determined using epidemiological observations from cancer registry data and from the literature. We estimated the benefit gained from RT use for each indication in the model using values published in the literature. We estimated the cost of RT for each indication using published Canadian data. The total benefit and cost was calculated for all indications combined. Results are reported in 2001 Canadian dollars.

Results: The mean benefit was 7 months of survival for each lung cancer patient treated with curative intent and 3 months of symptom control for each patient treated with palliative intent. The average cost was $9,881 per life year gained and $13,938 per year of symptom control gained. Sensitivity analysis revealed values between $7,905 and $19,762 per year of survival gain and between $10,368 and $27,875 per year of symptom control gained.

Conclusions: Using RT in the initial management of lung cancer can provide considerable gains in survival and symptom control. The cost of RT for the initial management of lung cancer is inexpensive compared with a common cut off of $50,000 per life year gained.

Cost-effectiveness versus cost-utility analysis of interventions for cancer: does adjusting for health-related quality of life really matter?

OBJECTIVE

The US Public Health Service Panel on Cost-Effectiveness has recommended the use of quality-adjusted life-years (QALYs) as the best way to estimate outcomes in a cost-effectiveness analysis. We evaluate the importance of this recommendation by assessing whether adjusting for health-related quality of life affects the ultimate resource allocation decision implied by the cost-effectiveness ratio for interventions aimed at cancer prevention and control.

METHODS

We identified 110 interventions in 39 articles for which both cost/life-year and cost/QALY were reported. Interventions were forms of prevention, early detection, or treatment of cancer. We calculated a Spearman correlation to assess the ordinal relationship between cost/life-year and cost/QALY. In addition, we employed various decision thresholds to assess whether the use of cost/life-year would yield different resource allocation decisions than the use of cost/QALY.

RESULTS

The correlation between cost/life-year and cost/QALY is 0.96 (P <.0001). Assuming a US dollars 50000 decision threshold, adjustment for quality of life would affect the implied choice in 5% of cases. With a US dollars 400000 threshold, adjustment for quality of life would affect choice for 2% of interventions.

CONCLUSIONS

For interventions aimed at cancer, the outcome measures of cost/life-year and cost/QALY are highly correlated with one another. Although adjusting for quality of life can make an important difference in the evaluation of alternative approaches to cancer prevention and control, it often does not.

Optimal management when unsuspected N2 nodal disease is identified during thoracotomy for lung cancer: cost-effectiveness analysis

OBJECTIVES

Whether to proceed with lung resection when N2 nodal disease is identified at the time of thoracotomy for lung cancer is controversial. A decision analysis model was developed to address this question.

METHODS

A meta-analysis was performed on data from reports published between 1990 and 2002 evaluating survival for (1) patients who were treated by initial resection for clinically unsuspected N2 nodal disease (initial resection) and (2) survival for patients undergoing resection after neoadjuvant therapy for N2 nodal disease (no initial resection). Hospital cost data for surgery were derived from our institution, and cost data for chemotherapy and radiation therapy were obtained from current literature. A decision model was developed to compare initial resection to no initial resection from the perspective of the medical center using survival, quality-adjusted life years survival, and cost-effectiveness as outcomes.

RESULTS

The no initial resection option provided better median survival (2.1 versus 1.7 years), quality-adjusted life years (1.8 versus 1.3), and cost-effectiveness, with an incremental cost-effectiveness ratio of 17,119 dollars/quality-adjusted life year. Outcomes were influenced by survival estimates for each treatment option.

CONCLUSIONS

When N2 nodal disease is discovered during thoracotomy, the approach of delaying resection until after neoadjuvant therapy provides the best survival and is more cost-effective. This is likely due to the beneficial effects of neoadjuvant therapy and the exclusion of patients with more aggressive disease from the surgical candidate pool.

Sleeve lobectomy or pneumonectomy: optimal management strategy using decision analysis techniques

BACKGROUND

The choice between sleeve lobectomy and pneumonectomy is controversial for patients with early-stage lung cancer and who have acceptable lung function.

METHODS

We performed a meta-analysis of results of sleeve lobectomy and pneumonectomy published in English from 1990 to 2003. A decision model was developed with 5-year survival, quality-adjusted life years (QALY), and cost effectiveness as the outcomes, and sensitivity analyses were performed.

RESULTS

The model favored sleeve lobectomy (3.5 percentage point survival advantage) when the reward was 5-year survival; the results were influenced primarily by the 5-year survival rates for patients who did not develop recurrent cancer. Sleeve lobectomy was strongly favored when the reward was QALY (1.53 QALY advantage). Sleeve lobectomy was more cost effective than pneumonectomy, and had an incremental cost effectiveness ratio of $1,300/QALY.

CONCLUSIONS

In patients with anatomically appropriate early-stage lung cancer, sleeve lobectomy offers better long-term survival and quality of life than does pneumonectomy and is more cost effective.

Solitary sites of metastatic disease in non-small cell lung cancer

Metastatic (stage IV) non-small cell lung cancer is a lethal disease, with few patients surviving longer than 5 years. Surgery is not an option, and adjuvant therapy regimens (platinum-based chemotherapy, radiation therapy, and supportive care) have been structured around palliation and maximizing the quality of life for patients. However, patients with solitary foci of metastatic disease represent a subgroup with a better prognosis. Studies have indicated that surgical resection may enhance the survival rate of patients in this setting. Patients who have resectable primary tumors and a solitary site of metastasis, based on a thorough metastatic work-up, benefit from surgical resection (primary tumor and solitary metastasis). The role of adjuvant chemotherapy and radiation depends on the individual and patient setting. There have been several case series indicating an improvement in the long-term (5-year) survival rates of patients after surgical resection of solitary metastases of the brain, adrenal gland, and other sites. Prospective trials will be required to determine the magnitude of benefit of surgical resection for patients and the role of multimodality therapy. The standard of care for patients with solitary metastases in non-small cell lung cancer should include consideration of surgical resection and ablation. Favorable criteria include control of the primary tumor, a negative metastatic survey, good performance status, and a significant metachronous interval.

Hypofractionated irradiation for non-small cell lung cancer

Large radiation fractions are an effective way of killing tumour cells but have generally been avoided in curative treatment of patients because of concerns of a disproportionate increase in late normal tissue toxicity. Radiobiological modelling of the effect of radiation on lung tumours and late-reacting normal tissues, which are more sensitive to large radiation fractions, has been undertaken. The biological effect of radiation on tumours is increased as the overall treatment time is shortened but this is not true for late-reacting normal tissue. Sample data are shown in which the relative increases in radiation effect on the tumour and late-reacting normal tissues are similar after hypofractionation. A favourable therapeutic ratio can be achieved because the bulk of normal tissue will receive a lower dose of radiation at a lower dose per fraction than the tumour, especially with current techniques where the volume of normal tissue irradiated can be sharply reduced. The clinical evidence confirms that lung toxicity is volume-dependent. It is the small Stage I and II tumours which are most likely to benefit from hypofractionated regimens, as the volumes to be treated are smaller and they have a lower incidence of distant metastases. Patients with Stage III tumours with favourable prognostic factors are nowadays treated with combined chemotherapy and radiotherapy and so for this group more conservative hypofractionation regimens are being explored. However, more advanced tumours may be treated with hypofractionation to lower total doses to achieve palliation and a modest degree of survival benefit.