Cost-effectiveness Analysis Comparing Conventional, Hypofractionated, and Intraoperative Radiotherapy for Early-Stage Breast Cancer

• Published in: JNCI : Journal of the National Cancer Institute Vol. 109; no. 11
• Main Authors: Deshmukh, Ashish A, Shirvani, Shervin M, Lal, Lincy, Swint, J Michael, Cantor, Scott B, Smith, Benjamin D, Likhacheva, Anna
• Format: Journal Article
• Language: English
• Published: United States 01.11.2017
• Subjects: Aged; Breast Neoplasms - pathology; Breast Neoplasms - radiotherapy; Breast Neoplasms - surgery; Cost-Benefit Analysis; Female; Humans; Intraoperative Care; Markov Chains; Mastectomy, Segmental; Middle Aged; Neoplasm Staging; Quality of Life; Quality-Adjusted Life Years; Radiation Dose Hypofractionation; Radiotherapy - economics; Radiotherapy, Adjuvant - economics; Randomized Controlled Trials as Topic; Sensitivity and Specificity
• ISSN: 0027-8874; 1460-2105; 1460-2105
• DOI: 10.1093/jnci/djx068

Early-stage breast cancer is among the most prevalent and costly malignancies treated in the American health care system. Adjuvant radiotherapy after lumpectomy represents a substantial portion of breast cancer expenditures. The relative value of novel radiotherapeutic approaches such as intraoperative radiotherapy (IORT) and hypofractionated whole breast irradiation (HF-WBI) compared with conventionally fractionated whole breast irradiation (CF-WBI) is unknown. Therefore, we used prospectively collected outcomes from randomized clinical trials (RCTs) to compare the cost-effectiveness of these approaches. We constructed a decision-analytic model that followed women who were treated with lumpectomy for early-stage breast cancer. Recurrence, mortality, complication rates, and utilities (five-year radiation-associated quality of life scores), were extracted from RCTs. Costs were based on Medicare reimbursement rates. Cost-effectiveness from societal and health care sector perspectives was estimated considering two scenarios-the first assumes that radiation-associated disutility persists five years after treatment, and the second assumes that disutility discontinues. Lifetime outcomes were summarized using incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses evaluated the robustness of the results. HF-WBI dominated CF-WBI (ie, resulted in higher quality-adjusted life-years [QALYs] and lower cost) in all scenarios. HF-WBI also had a greater likelihood of cost-effectiveness compared with IORT; under a societal perspective that assumes that radiation-associated disutility persists, HF-WBI results in an ICER of $17 024 per QALY compared with IORT with a probability of cost-effectiveness of 80% at the $100 000 per QALY willingness-to-pay threshold. If radiation-associated disutility is assumed to discontinue, the ICER is lower ($11 461/QALY), resulting in an even higher (83%) probability of relative cost-effectiveness. The ICER was most sensitive to the probability of metastasis and treatment cost. For women with early-stage breast cancer requiring adjuvant radiotherapy, HF-WBI is cost-effective compared with CF-WBI and IORT.