The cost effectiveness of 3D conformal radiation therapy compared with conventional techniques for patients with clinically localized prostate cancer

Clinical Implementation of Adaptive Helical Tomotherapy: A Unique Approach to Image-Guided Intensity Modulated Radiotherapy

Image-guided IMRT is a revolutionary concept whose clinical implementation is rapidly evolving. Methods of executing beam intensity modulation have included individually designed compensators, static multi-leaf collimators (MLC), dynamic MLC, and sequential (serial) tomotherapy. We have developed helical tomotherapy as an innovative solution to overcome some of the limitations of other IMRT systems. The unique physical design of helical tomotherapy allows the realization of the concepts of adaptive radiotherapy and conformal avoidance. In principle, these advances should improve normal tissue sparing and permit dose reconstruction and verification, thereby allowing significant biologically effective dose escalation.

Recent radiobiological findings can be translated into altered fractionation schemes that aim to improve the local control and long-term survival. This strategy is being tested at the University of Wisconsin using helical tomotherapy with its highly precise delivery and verification system along with meticulous and practical forms of immobilization. Innovative techniques such optical guidance, respiratory gating, and ultrasound assessments are being designed and tailored for helical tomotherapy use. The intrinsic capability of helical tomotherapy for megavoltage CT (MVCT) imaging for IMRT image-guidance is being optimized.

The unique features of helical tomotherapy might allow implementation of image-guided IMRT that was previously impossible or impractical. Here we review the technological, physical, and radiobiological rationale for the ongoing and upcoming clinical trials that will use image-guided IMRT in the form of helical tomotherapy; and we describe our plans for testing our hypotheses in a rigorous prospective fashion.

Costs of care in a matched pair comparison of intensity-modulated radiation therapy (IMRT) versus conventional radiation therapy (CRT) for the treatment of head and neck cancer

OBJECTIVES

Intensity-modulated radiation therapy (IMRT) has been rapidly adopted for the treatment of head and neck cancer. Limited comparative effectiveness data suggest that IMRT reduces the incidence of xerostomia and improves quality of life. We assess the cost of IMRT versus the older conventional radiation therapy (CRT) relative to other potential drivers of cost in patients with head and neck cancer.

METHODS

We compared patients treated with definitive radiation with or without chemotherapy for squamous cell carcinoma of the head and neck treated between 2000 and 2009. IMRT-treated patients were matched to CRT-treated patients by site, stage, and smoking status. Itemized billing charges were obtained for each patient and used to estimate cost using the Medicare fee schedule. Multivariate analysis was used to assess the influence of demographic, clinical, and treatment variables on total, pretreatment, during treatment, and follow-up costs.

RESULTS

Models indicate that compared with CRT, IMRT was associated with, on average, a $5881 increase in total costs (P=0.043), a $1700 decrease in pretreatment costs (P=0.014), a $4768 increase in costs during treatment (P=0.004), and no significant difference in follow-up costs. Positron emission tomography scans, cancer recurrence, and comorbidity were also associated with higher total costs in this sample.

CONCLUSIONS

Use of IMRT relative to CRT was strongly correlated with higher total costs, but disease control, patient comorbidity, and use of positron emission tomography also had significant effects on overall costs. Cost-effectiveness models should be developed to assess whether the potential benefits of IMRT are worth the associated investment.

Intensity-modulated radiation therapy and helical tomotherapy: its origin, benefits, and potential applications in veterinary medicine

Intensity-modulated radiation therapy (IMRT), especially image-guided IMRT as represented by helical tomotherapy, is a novel approach to therapy and is rapidly evolving. Both of these forms of therapy aim to allow targeted radiation delivery to the tumor volume while minimizing dose to the surrounding normal tissues. Adaptive radiation therapy and conformal avoidance are possible with intensity-modulated therapy and helical tomotherapy, which offer opportunities for improved local tumor control, decreased normal tissue toxicity, and improved survival and quality of life. Human and veterinary patients are likely to benefit from the continued development of this radiation delivery technique, and data over the next several years should be crucial in determining its true benefit.

Using decision analysis to determine the cost-effectiveness of intensity-modulated radiation therapy in the treatment of intermediate risk prostate cancer

BACKGROUND

The specific aim of this study is to evaluate the cost-effectiveness of intensity-modulated radiation therapy (IMRT) compared with three-dimensional conformal radiation therapy (3D-CRT) in the treatment of a 70-year-old with intermediate-risk prostate cancer.

METHODS

A Markov model was designed with the following states; posttreatment, hormone therapy, chemotherapy, and death. Transition probabilities from one state to another were calculated from rates derived from the literature for IMRT and 3D-CRT. Utility values for each health state were obtained from preliminary studies of preferences conducted at Fox Chase Cancer Center. The analysis took a payer's perspective. Expected mean costs, cost-effectiveness scatterplots, and cost acceptability curves were calculated with commercially available software.

RESULTS

The expected mean cost of patients undergoing IMRT was $47,931 with a survival of 6.27 quality-adjusted life years (QALYs). The expected mean cost of patients having 3D-CRT was $21,865 with a survival of 5.62 QALYs. The incremental cost-effectiveness comparing IMRT with CRT was $40,101/QALYs. Cost-effectiveness acceptability curve analysis revealed a 55.1% probability of IMRT being cost-effective at a $50,000/QALY willingness to pay.

CONCLUSION

Intensity-modulated radiation therapy was found to be cost-effective, however, at the upper limits of acceptability. The results, however, are dependent on the assumptions of improved biochemical disease-free survival with fewer patients undergoing subsequent salvage therapy and improved quality of life after the treatment. In the absence of prospective randomized trials, decision analysis can help inform physicians and health policy experts on the cost-effectiveness of emerging technologies.

Evidence-based review of three-dimensional conformal radiotherapy for localized prostate cancer: An ASTRO outcomes initiative

PURPOSE

To perform a systematic review of the evidence to determine the efficacy and effectiveness of three-dimensional conformal radiotherapy (3D-CRT) for localized prostate cancer; provide a clear presentation of the key clinical outcome questions related to the use of 3D-CRT in the treatment of localized prostate cancer that may be answered by a formal literature review; and provide concise information on whether 3D-CRT improves the clinical outcomes in the treatment of localized prostate cancer compared with conventional RT.

METHODS AND MATERIALS

We performed a systematic review of the literature through a structured process developed by the American Society for Therapeutic Radiology and Oncology's Outcomes Committee that involved the creation of a multidisciplinary task force, development of clinical outcome questions, a formal literature review and data abstraction, data review, and outside peer review.

RESULTS

Seven key clinical questions were identified. The results and task force conclusions of the literature review for each question are reported.

CONCLUSION

The technological goals of reducing morbidity with 3D-CRT have been achieved. Randomized trials and follow-up of completed trials remain necessary to address these clinical outcomes specifically with regard to patient subsets and the use of hormonal therapy.

A cost-outcome analysis of long-term adjuvant goserelin in addition to radiotherapy for locally advanced prostate cancer

To quantify the incremental costs and outcomes of using long-term adjuvant goserelin in addition to radiotherapy for locally advanced prostate cancer. The cost of radiotherapy for prostate cancer has been calculated using an activity-costing model. The total cost of administering adjuvant hormonal therapy for 3 years is based on local pharmacy charges plus typical physician billing fees and additional laboratory costs. Outcome data were obtained from the published EORTC 22,863 randomized trial comparing treatment of locally advanced prostate cancer with radiotherapy alone or in combination with 3 years of adjuvant goserelin. Using this information, the cost-effectiveness of adjuvant goserelin was calculated and expressed in terms of dollars per life-years (LY) gained. The total institutional costs of radiotherapy are $9000 Cdn. and the additional costs of providing adjuvant goserelin for 3 years are approximately $19,800 CDN. The improvement in outcome with the use of adjuvant goserelin was estimated to be 1.2 LY per patient treated, giving a cost-effectiveness ratio of $16,500 Cdn ($11,000 US) per LY from an institutional perspective. Our sensitivity analysis confirms the robustness of our findings since even in our "worst case" scenario the cost-effectiveness ratio was estimated to be $21,600 Can ($14,400 US) per LY gained. This figure is still below $50,000 US per LY gained which is the quoted current standard for cost-effectiveness. This analysis demonstrates that the use of long-term adjuvant goserelin for locally advanced prostate cancer provides substantial benefit at an acceptable cost.

Comparing the costs of radiation therapy and radical prostatectomy for the initial treatment of early-stage prostate cancer

PURPOSE

Radical prostatectomy and external-beam radiation are the most common treatments for localized prostate cancer. Given the absence of clinical consensus in favor of one treatment or the other, relative costs may be a significant factor. This study compares the direct medical costs during the month before and 9 months after diagnosis for patients treated primarily with external-beam radiation or radical prostatectomy for early-stage prostate cancer.

METHODS

Patients age 65 or older and coded by the Surveillance, Epidemiology, and End Results (SEER) registry as having been diagnosed with adenocarcinoma of the prostate treated primarily with external-beam radiation or radical prostatectomy during 1992 and 1993 were identified. The initial treatment costs, as measured by Medicare-approved payment amounts, for each strategy were analyzed using linked SEER-Medicare claims data after adjusting for differences in comorbidity and age. An intent-to-treat analysis was also performed to adjust for differences in staging between the two groups.

RESULTS

For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P <.001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P <.001).

CONCLUSION

For patients with early-stage prostate cancer, average costs during the initial treatment interval were at least 23% greater for radical prostatectomy than for external-beam radiation. Major limitations of the research include not studying costs after the initial treatment interval and questionable current applicability, given changes in management of early prostate cancer.

The economic costs of early stage prostate cancer

The economic costs of early stage prostate cancer are significant, and will likely increase as the proportion of older men grows in the population of industrialised nations. In the US, total costs have been estimated to range from US dollars 1.72 billion to US dollars 4.75 billion annually (1990 costs). Costs related to early stage prostate cancer arise from screening, staging and treatment. Cost-effectiveness models of population-based prostate cancer screening indicate that such screening could result in as much as US dollars 27.9 billion (1988 values) in charges to the US healthcare system. Evidence-based cancer-staging strategies would result in significant reduction of wasted expense. Rational allocation of healthcare dollars for prostate cancer screening and treatment may ultimately depend on data from randomised controlled trials.

An economic overview of prostate carcinoma

BACKGROUND

In the United States in 2000, 180,400 new cases of prostate carcinoma were expected to occur, with 31,900 men expected to die from this illness. In addition, prostate carcinoma is the cause of over half a million disability-adjusted life-years. This study summarizes the current body of published literature about the economics of prostate carcinoma.

METHODS

The authors used a MEDLINE-based literature review for relevant articles from 1990 to the present.

RESULTS

The authors' search returned 216 articles, 56 of which met the criteria of interest. Prostate carcinoma is costly to treat, currently averaging above $20,000 per case. Cost of care is directly related to stage of disease and comorbidity. Substantial geographic variation exists, even within small locales, with regard to care patterns and cost. In-hospital mortality, length of stay, and cost are inversely related to case volume. Care rendered in health maintenance organizations is generally less technologically intensive than in the fee-for-service sector. Out of the 18 cost studies examined, 13 were cost-minimization analyses and five assessed cost-effectiveness. From a cost perspective, laparoscopic pelvic node dissection was favored over an open pelvic procedure; 3D conformal radiation therapy was favored over 2D; and radiation therapy was favored over radical prostatectomy. Cost-effectiveness analyses favored the use of metastron, mitroxantone plus prednisone over prednisone alone, flutamine with either medical or surgical castration, and orchiectomy as the androgen suppression therapy.

CONCLUSIONS

The literature on the economics of prostate carcinoma is relatively meager. Most cost studies were done on small samples, had short follow-up periods, used charges rather than cost data, and did not include adequate representation of all stages of disease. Additional research is needed.

[Production process in external radiotherapy and cost-inducers research in 2 hospital units]

PURPOSE

To analyse the process of outpatient radiation therapy by dividing it into elementary acts, and to determine the cost-inducers (staff and machine time, equipment) in order to enhance the value of radiotherapy activity.

MATERIAL AND METHODS

The care process was analysed from 1 June 1997 to 1 September 1997, in two institutions (Centre hospitalo-universitaire de Saint Etienne and centre de Lutte contre le Cancer de Lyon), in terms of consumption of human and equipment means, representing a cost for the care institution. The valorization was expressed in physics units for material means, and in time units for human and heavy equipment. Parameters able to modify the consumption of means had been defined. The following data had been collected for each activity: patient characteristics, characteristics of the process, specific parameters of each activity, data related to the care staff and care unit.

RESULTS

The importance of the specific data of each activity was noteworthy. Two criteria modified the valorization: the complexity level of dosimetry and inclusion in a research trial. Total body irradiation and conformal radiotherapy were well individualized. There was no difference between the two care units. The lack of cost-inducers for the 'immobilization-simulation' activity reflects the large diversity of practice, and requires a global analysis of the 'treatment preparation' process.

CONCLUSION

The cost-inducers found in this study could permit the elaboration of the 'relative cost index' in radiation therapy. (The results obtained must be validated in other types of care units.) These relative cost indexes would describe the various phases of the treatment, such as treatment preparation, dosimetry, treatment, quality control. This approach is currently used by workshops in PMSI (Programme de Médicalisation des Systèmes d'Information) and NGAP (Nomenclature Générale des Actes Professionnels).

Localized prostate cancer

Much controversy still surrounds the diagnosis and treatment of localized prostate cancer. Urologists generally believe that early detection and aggressive surgical therapy saves lives despite the absence of confirmatory randomized trials. Furthermore, a recent survey of radiation oncologists and urologists revealed marked polarization toward their own specialties when asked how they would counsel patients on therapy for newly diagnosed localized disease. Some issues are not controversial, however. There is general agreement that pretreatment tumor characteristics, including serum prostate-specific antigen level at diagnosis, tumor grade, and clinical stage as judged by digital rectal examination, are important prognosticators for treatment outcomes independent of the type of treatment. Also, there is sufficient experience with standard therapies (radical prostatectomy and external beam radiotherapy) to counsel patients on the chance for cure and the expected incidence of acute and chronic toxicities. A comparative evaluation of various therapies for prostate cancer should include consideration of cancer control, acute toxicity, treatment-related quality of life issues, salvage of treatment failures, and cost. Within this context, we believe that newly diagnosed patients should be counseled on all available treatment options before embarking on a course of therapy.