Activity-Based Costing of Intensity-Modulated Proton versus Photon Therapy for Oropharyngeal Cancer

The Application of Time-Driven Activity-Based Costing in Oncology: A Systematic Review

OBJECTIVES

Time-driven activity-based costing (TD-ABC) holds promise to control costs and enhance value in oncology, but the current landscape of its applications remains uncharted. This study aimed to: (1) document the applications of TD-ABC in oncology and unveil its strengths and limitations, (2) assess the extent to which studies adhere to Kaplan and Porter's method, and (3) appraise study quality.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. To be eligible for inclusion, studies had to provide an empirical application of TD-ABC within oncology. Structured data extraction included key characteristics such as cancer type, perspective, and analysis setting. Quality was assessed using the TD-ABC Healthcare Consortium Consensus Statement checklist.

RESULTS

A total of 59 studies met the inclusion criteria, two-thirds of which were published within the last 5 years. Most studies were conducted in high-income countries and analyzed common cancer types. The provider's perspective (85%) dominated, and studies typically relied on single-institution data (76%). No study assessed costs over a complete cycle of care and most focused on the costs of radiotherapy (56%) or surgery (20%). Articles generally did not adhere to the seven-step method, and average study quality was low (52%), particularly because of inadequate content in methods and results.

CONCLUSIONS

Oncology has emerged as a productive field for TD-ABC analyses, showcasing the effectiveness of TD-ABC in capturing the costs of healthcare processes in which medical devices are integral to care delivery. Nevertheless, concerns arise because of the low overall study quality and the lack of a consistent methodology.

Toxicity and Oncologic Outcomes of Proton Radiotherapy for Oropharyngeal Cancer: A Systematic Review and Meta-Analysis

Intensity-modulated radiotherapy (IMRT) for oropharyngeal cancer (OPC) is associated with acute and late toxicities that impact patient quality of life. Proton radiotherapy (PRT) can reduce exposure to surrounding tissues, but the clinical magnitude of this advantage is unclear. A systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies reported toxicity or oncologic outcomes from patients treated with PRT for OPC. Pooled outcomes were estimated using random-effects models. Comparisons between PRT and IMRT were performed using log odds ratios. Primary outcomes were the pooled rates of adverse events, overall survival (OS), and progression-free survival (PFS). A total of 18 studies (16 retrospective, two prospective) consisting of 956 patients were identified. Pooled rates of acute grade 3+ toxicities were as follows: dermatitis 19%, mucositis 32%, xerostomia 1.3%, dysphagia 13%, and weight loss 1.4%. The pooled rate of acute hospitalizations was 10%. Among studies reporting late toxicities, the rates of grade 3+ xerostomia and dysphagia were 1.1% and 1.6%, respectively. Compared to IMRT, PRT was associated with lower rates of acute feeding tube use (21% versus 31%; P = 0.0012), but not long-term feeding tube use (1.4% versus 2.7%; P = 0.24). After PRT, OS at two and three years were 98% and 96%, while PFS at two and three years were 93% and 86%. PRT for patients with OPC is associated with favorable toxicity and oncologic outcomes. While randomized clinical trials are ongoing, these data provide additional evidence regarding the efficacy of PRT in the upfront treatment of OPC.

ACR-ARS Practice Parameter for the Performance of Proton Beam Therapy

Purpose

This practice parameter for the performance of proton beam radiation therapy was revised collaboratively by the American College of Radiology (ACR) and the American Radium Society (ARS). This practice parameter was developed to serve as a tool in the appropriate application of proton therapy in the care of cancer patients or other patients with conditions in which radiation therapy is indicated. It addresses clinical implementation of proton radiation therapy, including personnel qualifications, quality assurance (QA) standards, indications, and suggested documentation.

Materials and Methods

This practice parameter for the performance of proton beam radiation therapy was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters - Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS.

Results

The qualifications and responsibilities of personnel, such as the proton center Chief Medical Officer or Medical Director, Radiation Oncologist, Radiation Physicist, Dosimetrist and Therapist, are outlined, including the necessity for continuing medical education. Proton therapy standard clinical indications and methodologies of treatment management are outlined by disease site and treatment group (e.g. pediatrics) including documentation and the process of proton therapy workflow and equipment specifications. Additionally, this proton therapy practice parameter updates policies and procedures related to a quality assurance and performance improvement program (QAPI), patient education, infection control, and safety.

Conclusion

As proton therapy becomes more accessible to cancer patients, policies and procedures as outlined in this practice parameter will help ensure quality and safety programs are effectively implemented to optimize clinical care.

Use of the 40-gene Expression Profile (40-GEP) Test in Medicare-eligible Patients Diagnosed with Cutaneous Squamous Cell Carcinoma (cSCC) to Guide Adjuvant Radiation Therapy (ART) Decisions Leads to a Significant Reduction in Healthcare Costs

Objective

Adjuvant radiation therapy (ART) is often recommended for high-risk cSCC patients but carries significant costs and risks. This study aims to determine if utilizing the 40-GEP test to guide ART can reduce healthcare costs in cSCC management.

Methods

Medical claims data with new diagnoses of cSCC for the 12 months ending June 2022 in the Medicare (≥65 years) population (source: IQVIA claims database) were obtained and normalized to the general population for missingness. CPT codes associated with radiation therapy within one-year post diagnosis were used to establish adjuvant RT use (defined as 'ART'). Average weighted direct costs for four major ART modalities were calculated from published studies and (IQVIA). Sensitivity analysis was used to assess the financial impact of ART treatment using varying distributions of 40-GEP Class results.

Results

Normalized medical claims data identified 22,917 Medicare-eligible cSCC patients who received ART within the United States. The weighted average direct cost for ART, which includes the four most used CPT code-defined modalities (IGRT, IMRT, IMPT, and XRT), was $60,693 per patient, amounting to an annual projected ART cost of $1.4 billion. Using the distribution of 40-GEP results from published studies, utilization of a 40-GEP test result to avoid ART in these patients could save up to $972 million in Medicare-eligible population. Sensitivity analysis shows, depending upon the distribution of the 40-GEP results, that for every 10% of Class 2A test results omitting ART, an extra $38-66 million in annual savings is expected.

Limitations

Potential limitations include a need for more comprehensive patient information and the cost of ART-related complications.

Conclusion

Utilizing the 40-GEP test results to guide ART decision-making would result in material savings to Medicare.

A Systematic Review of the Economic Burden of Proton Therapy in Head and Neck Cancer

BACKGROUND

Radiation therapy is used to treat head and neck cancer (HNC) patients. Proton beam therapy (PBT) is one of the newer treatment options. This systematic review will describe the cost and cost-effectiveness of PBT compared with other first-line treatment options based on available literature and provide a better understanding of its usage in HNC in the future.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Systematic searches were conducted in PUBMED, EMBASE and SCOPUS till February 2022. Original pharmacoeconomic articles written in English that considered PBT for HNC were included; the title, abstract and full text of the search items were screened. The included studies were critically appraised using the Drummond Checklist followed by data extraction.

RESULTS

Eight of the ten included studies were of good quality; most were cost-effectiveness or cost comparison studies and used the Markov model and lifetime horizon. The dominant comparator was intensity-modulated radiotherapy. The willingness to pay threshold ranged from $30,828 to $150,000 per QALY. The incremental cost-effectiveness ratio (ICER) was between $4,436.1 and $695,000 per QALY. In HNC patients with human papillomavirus infection, the ICER was lower ($288,000/QALY) from the payer's perspective, but much higher ($390,000/QALY) from the societal perspective.

CONCLUSION

Our systematic review showed that appropriate patient selection can make PBT cost-effective. HPV-associated tumors can be cost-effectively treated with PBT. From the payer's perspective, PBT is a cost-effective treatment option. In younger patients, PBT can result in lesser incidence of adverse effects, and hence, can reduce the subsequent need for long-term supportive care. Lower fractionation schedules can also make PBT a cost-effective treatment.

Proton Beam Radiation Therapy for Oropharyngeal Squamous Cell Carcinoma

Purpose

To discuss the role of proton beam therapy (PBT) in the treatment of patients with oropharyngeal squamous cell carcinoma (OPSCC).

Materials and Methods

A review of the pertinent literature.

Results

Proton beam therapy likely results in reduced acute and late toxicity as compared with intensity-modulated radiation therapy (IMRT). The extent of the reduced toxicity, which may be modest, depends on the endpoint and technical factors such as pencil beam versus passive scattered PBT and adaptive replanning. The disease control rates after PBT are likely similar to those after IMRT.

Conclusion

Proton beam therapy is an attractive option to treat patients with OPSCC. Whether it becomes widely available depends on access.

Cost measurement in value-based healthcare: a systematic review

OBJECTIVE

Although value-based healthcare (VBHC) views accurate cost information to be crucial in the pursuit of value, little is known about how the costs of care should be measured. The aim of this review is to identify how costs are currently measured in VBHC, and which cost measurement methods can facilitate VBHC or value-based decision making.

DESIGN

Two reviewers systematically search the PubMed/MEDLINE, Embase, EBSCOhost and Web of Science databases for publications up to 1 January 2022 and follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify relevant studies for further analysis.

ELIGIBILITY CRITERIA

Studies should measure the costs of an intervention, treatment or care path and label the study as 'value based'. An inductive qualitative approach was used to identify studies that adopted management accounting techniques to identify if or how cost information facilitated VBHC by aiding decision-making.

RESULTS

We identified 1930 studies, of which 215 measured costs in a VBHC setting. Half of these studies measured hospital costs (110, 51.2%) and the rest relied on reimbursement amounts. Sophisticated costing methods that allocate both direct and indirect costs to care paths were seen as able to provide valuable managerial information by facilitating care path adjustments (39), benchmarking (38), the identification of cost drivers (47) and the measurement of total costs or cost savings (26). We found three best practices that were key to success in cost measurement: process mapping (33), expert input (17) and observations (24).

CONCLUSIONS

Cost information can facilitate VBHC. Time-driven activity-based costing (TDABC) is viewed as the best method although its ability to inform decision-making depends on how it is implemented. While costing short, or partial, care paths and surgical episodes produces accurate cost information, it provides only limited decision-making information. Practitioners are advised to focus on costing full care cycles and to consider both direct and indirect costs through TDABC.

Proton Therapy for Squamous Cell Carcinoma of the Head and Neck: Early Clinical Experience and Current Challenges

Simple Summary

Proton therapy is a promising type of radiation therapy used to destroy tumor cells. It has the potential to further improve the outcomes for patients with head and neck cancer since it allows to minimize the radiation dose to vital structures around the tumor, leading to less toxicity. This paper describes the current experience worldwide with proton therapy in head and neck cancer.

Abstract

Proton therapy (PT) is a promising development in radiation oncology, with the potential to further improve outcomes for patients with squamous cell carcinoma of the head and neck (HNSCC). By utilizing the finite range of protons, healthy tissue can be spared from beam exit doses that would otherwise be irradiated with photon-based treatments. Current evidence on PT for HNSCC is limited to comparative dosimetric analyses and retrospective single-institution series. As a consequence, the recognized indications for the reimbursement of PT remain scarce in most countries. Nevertheless, approximately 100 PT centers are in operation worldwide, and initial experiences for HNSCC are being reported. This review aims to summarize the results of the early clinical experience with PT for HNSCC and the challenges that are currently faced.