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2025 Cost analysis of alternate management schemes in early stage testicular seminoma
P r o c e e d i n g s of the 3 7 t h Annual ASTRO Meeting
275
2025 COST ANALYSIS OF ALTERNATE MANAGEMENT SCHEMES IN EARLY STAGE TESTICULAR SEMINOMA Navneet N. Sharda, M.D.; Timothy J. Kinsella, M.D.; Mark A. Ritter, M.D., Ph.D. Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI. Purpose: Optimal management of early stage testicuiar seminoma remains uncertain. Standard therapy includes inguinal orchidectomy followed by irradiation of the pelvic and para-aortic nodes. Due to the excellent survival rates (<4% seminoma specific mortality as per the Princess Margaret, Institute Goustave-Roussy experience), the o~tion of observation following orchidectomy has been proposed, with no diminution in absolute survival noted since salvage chemotherapy is effective in the treatment of early systemic relapse. However, the intensity of follow-up required if observation is chosen wilt likely add an increased medical cost burden which needs to be balanced against the cost of standard treatment using radiation therapy. We have therefore parformed a cost companson between these two management strategies in order to define any differences. Methods and Materials: All costs reported are adjusted to 1994 dollars and analysis is begun immediately post-orchidectomy. The cost of observation was calculated assuming a 15% relapse rate (1(P~-20~) over seven years of follow-up. The follow-up schedule was assumed identical to that commonly reported in the literature (Princess Margaret, Institute Gustave-Roussy, Royal Marsden), consisting of periodic CXR, CT abd/peMs, tumor markers and eXaminations. Chemotherapy costs associated with treatment of recurrences were generated from the inpatient hospital charges and physician billing of five patients who received three cycles of a standard United States regimen consisting of bleomycin, etoposide and cis-platinum in 1994. On average, four days of hospitalization were required. Radiolog~calcosts were also calculated from the actual patient billing records in 1994 and incremented at a rate of 3%/year over the length of proposed follow-up. Costs of irradiation and subsequent standard follow-up were similarly generated from the hospital charges and physician billing of five patients treated postoperatively. A 496 recurrence rate (0-6%) following adjuvant irradiation was assumed to be treated effectively with the same standard chemotherapy. Sensitivity analysis was performed to assess the impact of different recurrence rates for both observation and treatment. Actual institutional costs of treatment and services rendered were calculated assuming a 73% cost-to-charge ratio. The average HMO reimbursement of physician billing was calculated at 80%, the average reimbursement at our institution. Results: Truncating cumulative charges at seven years, the total charges for the observation arm and elective treatment arm were $27,200 and $18,500, respectively. Thus, over seven year~ observation was nine thousand dollars more expensive than treatment. Using the above cost-to-charge ratio for hospital services and reimbursement-to-billing ratio for physician fees, the actual cost of observation and treatment was $19,900 and actual cost of elective treatment was $13,650. Sensitivity analysis of recurrence rate variations showed that evenj 5% difference in recurrence rate correlated with a 4% difference in total costs of observation; thus, costs in the observation arm ranged from $19,080 to $20,713 for a recucrence rate of 10-2096. The average cost of observation exceeded that for elective irradiation by :$6,250. The 1995 projected incidence of testicular cancer in the United States is 7,100. Forty percent of the total testiculer tumors are noted to be pure seminoma and 80% of these present with Stage I-IIA disease; thus, the societal cost savings would be $14,200,000/year if elective irradiation of the pelvic and paraPaertic nodes were performed.
Conclusion: Elective irradiation of the pelvic and parwaortic nodes following orchidectomy in early stage testicular serninoma was noted to be significantly less expensive than observation. Absolute survival rates are expected to be equivalent, but a policy of observation, besides adding an additional burden of ensuring adequate follow-up, also requires significantly more resource utilization. The excess costs are primarily generated by the need for more frequent imaging studies necessary for the early detection of relapse.
2026 A COMPARISON OF RPA-DERIVED STAGING AND AJC STAGING IN HEAD & NECK CANCERS BASED ON RTOG DATA Cooper, Jay S. x Farnan, Nancy C.z; Asbel!, Sucha 03; Rotman, Marvin4; Marcial, Victor~; Fu, Karen K.6; McKerma, W. GilliesT; Emami, Bahman8 I. NYU Med Ctr.; 2 RTOG HQ; 3 Albert Einstein Med Ctr; 4. SUNY B'klyn; 5. U of Puerto Rico; 6. U.C.S.F.; 7. U. of Penn.; 8. Washington U Purpose/Objective: We sought to evaluate the prognostic efficacy of a new staging system for Head and Neck (H&N) cancers that was derived by recursive partitioning analysis (RPA). Materials & Methods: RPA is a statistical technique that can separate heterogeneous populations into homogeneous subgroups. It requires no a
priori knowledge of potential prognostic factors and can create groupings based on different outcome measures, such as local-regional relapse or survival. We analysed the outcome of 2,105 patients, who had squarnous cell carcinomas of the H&N region that were irradiated as part of four RTOG protocols. RPA created two different sets of subgroups (ie, defined stages) based upon (1) survival and (2) local-regional relapse. These RPA determined stages were compared to AJC defined stages Results: RPA created six stages of disease when survival was the measure of outcome and five stages when local-regional relapse was used, as compared to four stages in the AJC system. Although the assignment of tumors to stage groupings in the two systems did correlate, there was substantial disparity in assignment between the systems. This suggests that RPA recognizes factors that affect outcome which are not recognized by the AJC system RPA STAGE 1
2 3 4 5 6
% 2 YEAR SURVIVAL 92 81 59 35 22 g
% 5 YEAR SURVIVAL 90 58 35 18 9 0
AJC STAGE
% 2 YEAR SURVIVAL
% 5 YEAR SURVIVAL
1
88 69 50 30
73 47 30 15
2 3 4
Conclusion: RPA derived staging provides an alternative way to classify H&N tumors It can (I) disclose the presence of factors currently not recognized by the AJC system, (2) provide an additional basis for selection of patient specific therapy, and (3) potentially be used to improve the AJC system in the future.
275
2025 COST ANALYSIS OF ALTERNATE MANAGEMENT SCHEMES IN EARLY STAGE TESTICULAR SEMINOMA Navneet N. Sharda, M.D.; Timothy J. Kinsella, M.D.; Mark A. Ritter, M.D., Ph.D. Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI. Purpose: Optimal management of early stage testicuiar seminoma remains uncertain. Standard therapy includes inguinal orchidectomy followed by irradiation of the pelvic and para-aortic nodes. Due to the excellent survival rates (<4% seminoma specific mortality as per the Princess Margaret, Institute Goustave-Roussy experience), the o~tion of observation following orchidectomy has been proposed, with no diminution in absolute survival noted since salvage chemotherapy is effective in the treatment of early systemic relapse. However, the intensity of follow-up required if observation is chosen wilt likely add an increased medical cost burden which needs to be balanced against the cost of standard treatment using radiation therapy. We have therefore parformed a cost companson between these two management strategies in order to define any differences. Methods and Materials: All costs reported are adjusted to 1994 dollars and analysis is begun immediately post-orchidectomy. The cost of observation was calculated assuming a 15% relapse rate (1(P~-20~) over seven years of follow-up. The follow-up schedule was assumed identical to that commonly reported in the literature (Princess Margaret, Institute Gustave-Roussy, Royal Marsden), consisting of periodic CXR, CT abd/peMs, tumor markers and eXaminations. Chemotherapy costs associated with treatment of recurrences were generated from the inpatient hospital charges and physician billing of five patients who received three cycles of a standard United States regimen consisting of bleomycin, etoposide and cis-platinum in 1994. On average, four days of hospitalization were required. Radiolog~calcosts were also calculated from the actual patient billing records in 1994 and incremented at a rate of 3%/year over the length of proposed follow-up. Costs of irradiation and subsequent standard follow-up were similarly generated from the hospital charges and physician billing of five patients treated postoperatively. A 496 recurrence rate (0-6%) following adjuvant irradiation was assumed to be treated effectively with the same standard chemotherapy. Sensitivity analysis was performed to assess the impact of different recurrence rates for both observation and treatment. Actual institutional costs of treatment and services rendered were calculated assuming a 73% cost-to-charge ratio. The average HMO reimbursement of physician billing was calculated at 80%, the average reimbursement at our institution. Results: Truncating cumulative charges at seven years, the total charges for the observation arm and elective treatment arm were $27,200 and $18,500, respectively. Thus, over seven year~ observation was nine thousand dollars more expensive than treatment. Using the above cost-to-charge ratio for hospital services and reimbursement-to-billing ratio for physician fees, the actual cost of observation and treatment was $19,900 and actual cost of elective treatment was $13,650. Sensitivity analysis of recurrence rate variations showed that evenj 5% difference in recurrence rate correlated with a 4% difference in total costs of observation; thus, costs in the observation arm ranged from $19,080 to $20,713 for a recucrence rate of 10-2096. The average cost of observation exceeded that for elective irradiation by :$6,250. The 1995 projected incidence of testicular cancer in the United States is 7,100. Forty percent of the total testiculer tumors are noted to be pure seminoma and 80% of these present with Stage I-IIA disease; thus, the societal cost savings would be $14,200,000/year if elective irradiation of the pelvic and paraPaertic nodes were performed.
Conclusion: Elective irradiation of the pelvic and parwaortic nodes following orchidectomy in early stage testicular serninoma was noted to be significantly less expensive than observation. Absolute survival rates are expected to be equivalent, but a policy of observation, besides adding an additional burden of ensuring adequate follow-up, also requires significantly more resource utilization. The excess costs are primarily generated by the need for more frequent imaging studies necessary for the early detection of relapse.
2026 A COMPARISON OF RPA-DERIVED STAGING AND AJC STAGING IN HEAD & NECK CANCERS BASED ON RTOG DATA Cooper, Jay S. x Farnan, Nancy C.z; Asbel!, Sucha 03; Rotman, Marvin4; Marcial, Victor~; Fu, Karen K.6; McKerma, W. GilliesT; Emami, Bahman8 I. NYU Med Ctr.; 2 RTOG HQ; 3 Albert Einstein Med Ctr; 4. SUNY B'klyn; 5. U of Puerto Rico; 6. U.C.S.F.; 7. U. of Penn.; 8. Washington U Purpose/Objective: We sought to evaluate the prognostic efficacy of a new staging system for Head and Neck (H&N) cancers that was derived by recursive partitioning analysis (RPA). Materials & Methods: RPA is a statistical technique that can separate heterogeneous populations into homogeneous subgroups. It requires no a
priori knowledge of potential prognostic factors and can create groupings based on different outcome measures, such as local-regional relapse or survival. We analysed the outcome of 2,105 patients, who had squarnous cell carcinomas of the H&N region that were irradiated as part of four RTOG protocols. RPA created two different sets of subgroups (ie, defined stages) based upon (1) survival and (2) local-regional relapse. These RPA determined stages were compared to AJC defined stages Results: RPA created six stages of disease when survival was the measure of outcome and five stages when local-regional relapse was used, as compared to four stages in the AJC system. Although the assignment of tumors to stage groupings in the two systems did correlate, there was substantial disparity in assignment between the systems. This suggests that RPA recognizes factors that affect outcome which are not recognized by the AJC system RPA STAGE 1
2 3 4 5 6
% 2 YEAR SURVIVAL 92 81 59 35 22 g
% 5 YEAR SURVIVAL 90 58 35 18 9 0
AJC STAGE
% 2 YEAR SURVIVAL
% 5 YEAR SURVIVAL
1
88 69 50 30
73 47 30 15
2 3 4
Conclusion: RPA derived staging provides an alternative way to classify H&N tumors It can (I) disclose the presence of factors currently not recognized by the AJC system, (2) provide an additional basis for selection of patient specific therapy, and (3) potentially be used to improve the AJC system in the future.