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Wolff HB, Alberts L, van der Linden N, Bongers ML, Verstegen NE, Lagerwaard FJ, Hofman FN, Uyl-de Groot CA, Senan S, El Sharouni SY, Kastelijn EA, Schramel FMNH, Coupé VMH. Cost-effectiveness of stereotactic body radiation therapy versus video assisted thoracic surgery in medically operable stage I non-small cell lung cancer: A modeling study. Lung Cancer 2020; 141:89-96. [PMID: 31982640 DOI: 10.1016/j.lungcan.2020.01.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/13/2019] [Accepted: 01/11/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Stage I non-small cell lung cancer (NSCLC) can be treated with either Stereotactic Body Radiotherapy (SBRT) or Video Assisted Thoracic Surgery (VATS) resection. To support decision making, not only the impact on survival needs to be taken into account, but also on quality of life, costs and cost-effectiveness. Therefore, we performed a cost-effectiveness analysis comparing SBRT to VATS resection with respect to quality adjusted life years (QALY) lived and costs in operable stage I NSCLC. MATERIALS AND METHODS Patient level and aggregate data from eight Dutch databases were used to estimate costs, health utilities, recurrence free and overall survival. Propensity score matching was used to minimize selection bias in these studies. A microsimulation model predicting lifetime outcomes after treatment in stage I NSCLC patients was used for the cost-effectiveness analysis. Model outcomes for the two treatments were overall survival, QALYs, and total costs. We used a Dutch health care perspective with 1.5 % discounting for health effects, and 4 % discounting for costs, using 2018 cost data. The impact of model parameter uncertainty was assessed with deterministic and probabilistic sensitivity analyses. RESULTS Patients receiving either VATS resection or SBRT were estimated to live 5.81 and 5.86 discounted QALYs, respectively. Average discounted lifetime costs in the VATS group were €29,269 versus €21,175 for SBRT. Difference in 90-day excess mortality between SBRT and VATS resection was the main driver for the difference in QALYs. SBRT was dominant in at least 74 % of the probabilistic simulations. CONCLUSION Using a microsimulation model to combine available evidence on survival, costs, and health utilities in a cost-effectiveness analysis for stage I NSCLC led to the conclusion that SBRT dominates VATS resection in the majority of simulations.
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Affiliation(s)
- Henri B Wolff
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, the Netherlands.
| | - Leonie Alberts
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Naomi van der Linden
- Department of Health Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Mathilda L Bongers
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - Naomi E Verstegen
- Department of Radiation Oncology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Frank J Lagerwaard
- Department of Radiation Oncology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Frederik N Hofman
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Carin A Uyl-de Groot
- Department of Health Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Sherif Y El Sharouni
- Department of Radiotherapy, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | | | - Veerle M H Coupé
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
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Verstegen NE, Maat APWM, Lagerwaard FJ, Paul MA, Versteegh MI, Joosten JJ, Lastdrager W, Smit EF, Slotman BJ, Nuyttens JJME, Senan S. Salvage surgery for local failures after stereotactic ablative radiotherapy for early stage non-small cell lung cancer. Radiat Oncol 2016; 11:131. [PMID: 27716240 PMCID: PMC5048455 DOI: 10.1186/s13014-016-0706-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/20/2016] [Indexed: 12/17/2022] Open
Abstract
Introduction The literature on surgical salvage, i.e. lung resections in patients who develop a local recurrence following stereotactic ablative radiotherapy (SABR), is limited. We describe our experience with salvage surgery in nine patients who developed a local recurrence following SABR for early stage non-small cell lung cancer (NSCLC). Methods Patients who underwent surgical salvage for a local recurrence following SABR for NSCLC were identified from two Dutch institutional databases. Complications were scored using the Dindo-Clavien-classification. Results Nine patients who underwent surgery for a local recurrence were identified. Median time to local recurrence was 22 months. Recurrences were diagnosed with CT- and/or 18FDG-PET-imaging, with four patients also having a pre-surgical pathological diagnosis. Extensive adhesions were observed during two resections, requiring conversion from a thoracoscopic procedure to thoracotomy during one of these procedures. Three patients experienced complications post-surgery; grade 2 (N = 2) and grade 3a (N = 1), respectively. All resection specimens showed viable tumor cells. Median length of hospital stay was 8 days (range 5–15 days) and 30-day mortality was 0 %. Lymph node dissection revealed mediastinal metastases in 3 patients, all of whom received adjuvant therapy. Conclusions Our experience with nine surgical procedures for local recurrences post-SABR revealed two grade IIIa complications, and a 30-day mortality of 0 %, suggesting that salvage surgery can be safely performed after SABR.
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Affiliation(s)
- Naomi E Verstegen
- Department of Radiation Oncology, VU University Medical Center Amsterdam, De Boelelaan 1117, Postbox 7057, 1007 MB, Amsterdam, The Netherlands
| | - Alexander P W M Maat
- Department of Cardiothoracic Surgery, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frank J Lagerwaard
- Department of Radiation Oncology, VU University Medical Center Amsterdam, De Boelelaan 1117, Postbox 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Marinus A Paul
- Department of Cardiothoracic Surgery, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Michel I Versteegh
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris J Joosten
- Department of Surgery, Westfriesgasthuis Hoorn, Hoorn, The Netherlands
| | - Willem Lastdrager
- Department of Surgery, Gelre Hospital Apeldoorn, Apeldoorn, The Netherlands
| | - Egbert F Smit
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center Amsterdam, De Boelelaan 1117, Postbox 7057, 1007 MB, Amsterdam, The Netherlands
| | - Joost J M E Nuyttens
- Department of Radiation Oncology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, VU University Medical Center Amsterdam, De Boelelaan 1117, Postbox 7057, 1007 MB, Amsterdam, The Netherlands
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Abstract
An increase in the number of predominantly elderly patients with early-stage non-small-cell lung cancer is anticipated in many Western populations. Patients often have major co-morbidities and are at increased risk for surgical morbidity and mortality. In the past decade, the use of stereotactic ablative radiotherapy (SABR) has achieved excellent results, with only mild toxicity in such vulnerable patient groups, leading to SABR becoming accepted as a standard of care for unfit patients in several countries. The planning and delivery of SABR has rapidly improved in recent years, particularly with the use of 'on-board' imaging at treatment units, and shortened treatment delivery times. Increasingly, more central tumors are being treated using lower doses per fraction (so-called risk-adapted schemes). It is also becoming clear that long-term follow-up should take place at specialist centers in order to distinguish the evolving fibrosis that is frequently observed from the relatively infrequent local recurrences. Given the high local control rates and limited toxicity, increasing attention is being paid to the use of SABR in the subgroup of so-called borderline operable patients, and clinical trials comparing surgery and SABR in these patients are ongoing.
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Affiliation(s)
- N E Verstegen
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Verstegen NE, Oosterhuis JWA, Palma DA, Rodrigues G, Lagerwaard FJ, van der Elst A, Mollema R, van Tets WF, Warner A, Joosten JJA, Amir MI, Haasbeek CJA, Smit EF, Slotman BJ, Senan S. Stage I-II non-small-cell lung cancer treated using either stereotactic ablative radiotherapy (SABR) or lobectomy by video-assisted thoracoscopic surgery (VATS): outcomes of a propensity score-matched analysis. Ann Oncol 2013; 24:1543-8. [PMID: 23425947 DOI: 10.1093/annonc/mdt026] [Citation(s) in RCA: 218] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) lobectomy and stereotactic ablative radiotherapy (SABR) are both used for early-stage non-small-cell lung cancer. We carried out a propensity score-matched analysis to compare locoregional control (LRC). PATIENTS AND METHODS VATS lobectomy data from six hospitals were retrospectively accessed; SABR data were obtained from a single institution database. Patients were matched using propensity scores based on cTNM stage, age, gender, Charlson comorbidity score, lung function and performance score. Eighty-six VATS and 527 SABR patients were matched blinded to outcome (1:1 ratio, caliper distance 0.025). Locoregional failure was defined as recurrence in/adjacent to the planning target volume/surgical margins, ipsilateral hilum or mediastinum. Recurrences were either biopsy-confirmed or had to be PET-positive and reviewed by a tumor board. RESULTS The matched cohort consisted of 64 SABR and 64 VATS patients with the median follow-up of 30 and 16 months, respectively. Post-SABR LRC rates were superior at 1 and 3 years (96.8% and 93.3% versus 86.9% and 82.6%, respectively, P = 0.04). Distant recurrences and overall survival (OS) were not significantly different. CONCLUSION This retrospective analysis found a superior LRC after SABR compared with VATS lobectomy, but OS did not differ. Our findings support the need to compare both treatments in a randomized, controlled trial.
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Affiliation(s)
- N E Verstegen
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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Senthi S, Verstegen NE, Senan S. Treatment of peripheral lung tumors arising after a prior pneumonectomy. Chest 2012; 142:263. [PMID: 22796856 DOI: 10.1378/chest.12-0378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Sashendra Senthi
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Naomi E Verstegen
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Senan S, Verstegen NE, Palma D, Rodrigues G, Lagerwaard FJ, van der Elst A, Mollema R, van Tets WF, Warner A, Joosten JJ, Amir MI, Haasbeek CJ, Smit EF, Slotman BJ, Oosterhuis JW. Stages I-II non-small cell lung cancer treated using either lobectomy by video-assisted thoracoscopic surgery (VATS) or stereotactic ablative radiotherapy (SABR): Outcomes of a propensity score-matched analysis. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.7009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7009 Background: VATS procedures are increasingly used in early-stage NSCLC. As high local control rates are also seen with stereotactic ablative radiotherapy (SABR), we performed a propensity score-matched analysistocompare loco-regional control (LRC) after both treatments. Methods: Patients with stage I-II NSCLC treated at 6 hospitals (1 university and 5 regional hospitals) with VATS lobectomy were eligible. Details of SABR patients were obtained from a single-institutional database. All VATS-lobectomies were performed in accordance with ESTS guidelines. Patients were matched using propensity scores based on cTNM, age, gender, Charlson comorbidity score, lung function and performance score. Matching was performed blinded to all outcomes. Excluded were: synchronous lung tumors, COPD GOLD class 4 or history of prior lung cancer. A total of 86 VATS- and 527 SABR patients were eligible for matching (1:1 ratio, caliper distance of 0.025 without replacement). Loco-regional failure was defined as recurrence in/adjacent to the radiation planning target volume or surgical margins, the ipsilateral hilum or mediastinum. Recurrences were either biopsy-confirmed or PET-positive and reviewed by a tumor board. Patients upstaged during VATS and those developing recurrence were treated in accordance with national guidelines. Results: The matched cohort consisted of 128 patients with cT1-3N0 NSCLC following SABR (n=64) or VATS-lobectomy (n=64). Median follow-up was 30 and 16 months, respectively. The groups were well matched on baseline variables. SABR patients had better LRC rates at 1- and 3-years (96.8% and 93.3% vs. 86.9% and 82.6%, respectively, p= .03). Three-year progression-free survival (PFS) did not significantly differ after SABR (79.3% versus 63.2%, p = .09). Distant recurrence rates and overall survival (OS) did not significantly differ. Conclusions: Although loco-regional control was superior after SABR compared to VATS-lobectomy, PFS and OS did not differ at this time-point. Our findings support the current randomized controlled trial evaluating both treatments (ACOSOG Z4099).
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Affiliation(s)
- Suresh Senan
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Naomi E Verstegen
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - David Palma
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | | | - Frank J Lagerwaard
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | | | - R Mollema
- Medisch Centrum Alkmaar, Alkmaar, Netherlands
| | - W F van Tets
- Sint Lucas Andreas Ziekenhuis, Amsterdam, Netherlands
| | | | | | - M I Amir
- Waterlandziekenhuis, Purmerend, Netherlands
| | - Cornelis J Haasbeek
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Egbert F Smit
- Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, Netherlands
| | - Ben J. Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
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Lagerwaard FJ, Verstegen NE, Haasbeek CJ, Slotman BJ, Paul MA, Smit EF, Senan S. Outcomes of Stereotactic Ablative Radiotherapy in Patients With Potentially Operable Stage I Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2012; 83:348-53. [PMID: 22104360 DOI: 10.1016/j.ijrobp.2011.06.2003] [Citation(s) in RCA: 247] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 05/18/2011] [Accepted: 06/25/2011] [Indexed: 12/25/2022]
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Hopmans W, Verstegen NE, Haasbeek CJ, Damman OC, Slotman BJ, Timmermans DR, Senan S. An evaluation of websites providing patient information on stereotactic body radiation therapy (SBRT) for stage I lung cancer in three Western European countries. J Radiosurg SBRT 2012; 1:303-315. [PMID: 29296331 PMCID: PMC5658865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Accepted: 03/08/2012] [Indexed: 06/07/2023]
Abstract
BACKGROUND The use of stereotactic body radiation therapy (SBRT) for the treatment of stage I lung cancer has been associated with improvements in population-based survival in Western Europe. As patients are increasingly accessing the Internet for information on health-related topics, we evaluated the quality, usability and readability of online patient information about SBRT in three adjacent Western European countries. MATERIALS AND METHODS We conducted a web search and analysis between May - June 2011. Thirteen key terms were entered into the Google search engine. We analyzed websites from the Netherlands, Germany and the United Kingdom, by using the DISCERN instrument, a tool designed to assess the quality of health information on treatment choices. In addition, websites' usability and readability were examined. RESULTS We identified a total of 20 websites. None of the websites received an excellent or good quality rating and only two were rated as fair (both from the United Kingdom). DISCERN scores rated 55% (N = 11) of the websites as poor, and 35% (N = 7) as very poor. Dutch websites had the lowest scores. Five websites attained relatively high usability scores, and none had sufficient readability scores. CONCLUSIONS Despite the fact that SBRT is widely used as a standard therapy in elderly patients with stage I NSCLC in the Netherlands, only limited high quality information is available on the Internet. Improvements in quality information available on the Internet are required in order to increase patient participation in decision-making.
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Affiliation(s)
- Wendy Hopmans
- Department of Public and Occupational Health and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Naomi E. Verstegen
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Cornelis J.A. Haasbeek
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Olga C. Damman
- Department of Public and Occupational Health and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Ben J. Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Danielle R.M. Timmermans
- Department of Public and Occupational Health and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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