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A Decision Analysis of Primary Radiation Therapy and Androgen Deprivation Therapy Versus Radical Prostatectomy for High-Risk Prostate Cancer
S500
International Journal of Radiation Oncology Biology Physics
2777
comparison modality, and year of publication. Additionally, data regarding the burden of disease was obtained through publicly available sources and included the prevalence, incidence, person-years life lost, and disabilityadjusted life years for each disease site. A logistic regression model was built and tested to explore whether certain treatment modalities were more frequently compared to radiation therapy. Disease sites studied were also tested for correlations to disease burden on society. Results: Of the 58 included articles, the most frequent disease sites studied were prostate (22.4%), metastatic disease (17.3%), breast (15.5%), and head and neck (10.3%). Several sites of disease have not had any published cost-effectiveness articles including skin and non-prostate GU. Radiation therapy was most frequently compared to another radiation modality (53.5%), followed by a comparison to observation (27.6%) and a comparison to surgery (15.5%). A comparison between two radiation modalities was found to be significantly more recently published (OR 1.15, p Z .02) while a comparison to observation was significantly more likely to published in the past (OR .85, p Z .02). A correlation was found between the relative proportion of each disease site studied and the United States prevalence (p < .001), but not with incidence (p Z .07), disabilityadjusted life years (p Z .42), or person-years life lost (p Z .31). Conclusions: While healthcare costs in the United States have continued to increase, there are relatively few cost-effectiveness studies focused on radiation therapy. The studies that have been performed have most frequently compared radiation modalities and the proportions of disease sites studied are correlated with disease incidence. There is a great need for robust cost-effectiveness research in radiation oncology. Author Disclosure: A.P. Dosoretz: None. J. Stahl: None. S. Aneja: None. S. Lloyd: None. J. Yu: None.
A Decision Analysis of Primary Radiation Therapy and Androgen Deprivation Therapy Versus Radical Prostatectomy for High-Risk Prostate Cancer J.A. Dorth,1 W.R. Lee,2 and E.R. Myers3; 1University Hospitals - Seidman Cancer Center, Cleveland, OH, 2Duke Cancer Institute, Durham, NC, 3 Duke University Medical Center, Durham, NC Purpose/Objective(s): A previous decision analysis compared primary radiation therapy (RT) and androgen deprivation therapy (ADT) to radical prostatectomy (RP) for men 65 years old with resulting QALEs of 9.3 and 8.0 QALYs, respectively (Sher, Cancer, 2012). However, this analysis did not incorporate the use of curative-intent, salvage therapy for local recurrence or treatment cost. Materials/Methods: The base case was a 65 year-old man diagnosed with high-risk prostate cancer (T1c, GS 8-10, PSA >10). This decision analysis compared upfront RT + 2 years of ADT versus RP with selective postoperative RT + 2 years of ADT for postoperative risk factors. Salvage therapy included RP or RT, depending on initial treatment delivered. Assumptions were based on the highest-quality data available: post-operative risk factors from Partin Tables, biochemical failure (BF) post-RP from the Kattan nomogram, BF post-RP + RT + ADT from RTOG 96-01, BF post-RT + ADT from RTOG 92-02, and BF post-salvage RT or RP from retrospective analyses. Treatment-related effects including mortality, acute toxicity, and moderate-to-severe erectile dysfunction, gastrointestinal or genitourinary side effects were incorporated into calculations of QALY. Yearly, age-related mortality estimates were taken from CDC life tables. Costs were estimated from the payer’s perspective using Medicare reimbursements in 2011 United States dollars. A Markov model was developed to model chance events with yearly cycles until death. Microsimulation incorporated parameter uncertainty to estimate QALE while tracking individual patients’ disease history. Results: In the base case, the mean QALE was 10.25 (95% CI, 1.8-20) versus 10.22 (95% CI, 1.3-20) QALYs for RT + ADT versus RP, respectively. The mean cost of treatment was $40,863 (95% CI, 1,401-181,778) versus $36,144 (95% CI, 117-157,556) for RT + ADT and RP, respectively. The mean ICER for RP compared to RT + ADT is 15,578 (95% CI, 1,029,978 - 812,230). Cost-effectiveness acceptability suggests there is considerable uncertainty about which strategy is optimal. Conclusions: When incorporating salvage therapy for local recurrence of high-risk prostate cancer, there is no clear difference in QALE or ICER between RT + ADT versus RP as primary treatment strategies. Author Disclosure: J.A. Dorth: None. W.R. Lee: None. E.R. Myers: None.
2778 Cost-Effectiveness Research and Radiation Oncology: An Analysis of the Published Literature A.P. Dosoretz,1 J. Stahl,2 S. Aneja,1 S. Lloyd,1 and J. Yu1; 1Yale-New Haven Hospital, New Haven, CT, 2University of Florida College of Medicine, Gainesville, FL Purpose/Objective(s): The continued rise of healthcare costs in the United States has served as an impetus for increasing interest in the use of cost-effectiveness analysis to aid in improving the value of healthcare delivery. The high burden of cancer care and the multiple available therapeutic modalities make radiation oncology a field in which cost-effectiveness studies could significantly impact healthcare costs and patient care. The purpose of this study was to identify and analyze the published cost-effectiveness research that has focused on radiation therapy. We also aimed to better understand the relative proportions of disease sites studied, modalities compared, and trends over time. Materials/Methods: A PubMed search was performed using the following terms: “cost” and “effectiveness” and “radiation.” A total of 704 articles were identified. Of these studies, 58 specifically analyzed the cost-effectiveness of radiation therapy as definitive treatment or as part of combination therapy. The included studies were analyzed by disease site,
2779 Utilization of Hypofractionation in an Insured Population H.A. Curry1 and R. Jagsi2; 1Eviti Inc., Philadelphia, PA, 2University of Michigan, Ann Arbor, MI Purpose/Objective(s): As the population ages, the prevalence of cancer relative to other diseases is expected to increase, as is the financial burden to patients and society as a whole. Hypofractionation (HF) represents a potential means to decrease economic and indirect burdens associated with the delivery of radiation therapy for many patients. To evaluate the clinical use of HF for patients with either stage I-IIA breast cancer or bone metastases in a working age, insured population, we assessed treatment plans submitted for preauthorization through eviti, Inc’s web-based application. Materials/Methods: A proprietary web-based application enables oncology providers to obtain real time automated precertification for patients insured by payers across the United States that utilize the eviti platform. The platform evaluates treatment plans for consistency with evidence based medicine and compliance with specific payer policies and plan language. All preauthorization requests for radiation treatment submitted during an 18 month period from June 1, 2011-December 7, 2012 were evaluated for the use of HF. HF was defined as daily fraction size >2.5 Gy for breast and >3 Gy for bone metastases. We also evaluated the average cost for delivery of conventionally fractionated treatment vs HF treatment based on average reimbursement rates from three of eviti, Inc.’s largest payers. Results: A total of 3379 cases were submitted of which 279 were bone metastases and 370 were breast. We evaluated the overall rates and within any state with at least 10 submitted plans. Rates of utilization of HF in bone ranged from 0% in IN and MD to 40% in SD. Rates for HF in breast ranged from 0% in FL and OH to 20% in MO. Overall, only 31 of 279 or 11% (95% CI Z 7-15%) of bone metastases plans and 32 of 370 or 9% (95% CI Z 6-12%) of breast plans used HF. Delivery cost of a course of RT for bone metastases was $2,580 for 30 Gy in 10 fractions vs $258 for 8 Gy x 1 vs $1,235 for 20 Gy in 5 fractions. For breast treatment, cost for a typical course of 50 Gy in 25 fractions was $6,451 vs $4,128 for 42.5 Gy in 16 fractions. The cost difference was even greater if IMRT was utilized
International Journal of Radiation Oncology Biology Physics
2777
comparison modality, and year of publication. Additionally, data regarding the burden of disease was obtained through publicly available sources and included the prevalence, incidence, person-years life lost, and disabilityadjusted life years for each disease site. A logistic regression model was built and tested to explore whether certain treatment modalities were more frequently compared to radiation therapy. Disease sites studied were also tested for correlations to disease burden on society. Results: Of the 58 included articles, the most frequent disease sites studied were prostate (22.4%), metastatic disease (17.3%), breast (15.5%), and head and neck (10.3%). Several sites of disease have not had any published cost-effectiveness articles including skin and non-prostate GU. Radiation therapy was most frequently compared to another radiation modality (53.5%), followed by a comparison to observation (27.6%) and a comparison to surgery (15.5%). A comparison between two radiation modalities was found to be significantly more recently published (OR 1.15, p Z .02) while a comparison to observation was significantly more likely to published in the past (OR .85, p Z .02). A correlation was found between the relative proportion of each disease site studied and the United States prevalence (p < .001), but not with incidence (p Z .07), disabilityadjusted life years (p Z .42), or person-years life lost (p Z .31). Conclusions: While healthcare costs in the United States have continued to increase, there are relatively few cost-effectiveness studies focused on radiation therapy. The studies that have been performed have most frequently compared radiation modalities and the proportions of disease sites studied are correlated with disease incidence. There is a great need for robust cost-effectiveness research in radiation oncology. Author Disclosure: A.P. Dosoretz: None. J. Stahl: None. S. Aneja: None. S. Lloyd: None. J. Yu: None.
A Decision Analysis of Primary Radiation Therapy and Androgen Deprivation Therapy Versus Radical Prostatectomy for High-Risk Prostate Cancer J.A. Dorth,1 W.R. Lee,2 and E.R. Myers3; 1University Hospitals - Seidman Cancer Center, Cleveland, OH, 2Duke Cancer Institute, Durham, NC, 3 Duke University Medical Center, Durham, NC Purpose/Objective(s): A previous decision analysis compared primary radiation therapy (RT) and androgen deprivation therapy (ADT) to radical prostatectomy (RP) for men 65 years old with resulting QALEs of 9.3 and 8.0 QALYs, respectively (Sher, Cancer, 2012). However, this analysis did not incorporate the use of curative-intent, salvage therapy for local recurrence or treatment cost. Materials/Methods: The base case was a 65 year-old man diagnosed with high-risk prostate cancer (T1c, GS 8-10, PSA >10). This decision analysis compared upfront RT + 2 years of ADT versus RP with selective postoperative RT + 2 years of ADT for postoperative risk factors. Salvage therapy included RP or RT, depending on initial treatment delivered. Assumptions were based on the highest-quality data available: post-operative risk factors from Partin Tables, biochemical failure (BF) post-RP from the Kattan nomogram, BF post-RP + RT + ADT from RTOG 96-01, BF post-RT + ADT from RTOG 92-02, and BF post-salvage RT or RP from retrospective analyses. Treatment-related effects including mortality, acute toxicity, and moderate-to-severe erectile dysfunction, gastrointestinal or genitourinary side effects were incorporated into calculations of QALY. Yearly, age-related mortality estimates were taken from CDC life tables. Costs were estimated from the payer’s perspective using Medicare reimbursements in 2011 United States dollars. A Markov model was developed to model chance events with yearly cycles until death. Microsimulation incorporated parameter uncertainty to estimate QALE while tracking individual patients’ disease history. Results: In the base case, the mean QALE was 10.25 (95% CI, 1.8-20) versus 10.22 (95% CI, 1.3-20) QALYs for RT + ADT versus RP, respectively. The mean cost of treatment was $40,863 (95% CI, 1,401-181,778) versus $36,144 (95% CI, 117-157,556) for RT + ADT and RP, respectively. The mean ICER for RP compared to RT + ADT is 15,578 (95% CI, 1,029,978 - 812,230). Cost-effectiveness acceptability suggests there is considerable uncertainty about which strategy is optimal. Conclusions: When incorporating salvage therapy for local recurrence of high-risk prostate cancer, there is no clear difference in QALE or ICER between RT + ADT versus RP as primary treatment strategies. Author Disclosure: J.A. Dorth: None. W.R. Lee: None. E.R. Myers: None.
2778 Cost-Effectiveness Research and Radiation Oncology: An Analysis of the Published Literature A.P. Dosoretz,1 J. Stahl,2 S. Aneja,1 S. Lloyd,1 and J. Yu1; 1Yale-New Haven Hospital, New Haven, CT, 2University of Florida College of Medicine, Gainesville, FL Purpose/Objective(s): The continued rise of healthcare costs in the United States has served as an impetus for increasing interest in the use of cost-effectiveness analysis to aid in improving the value of healthcare delivery. The high burden of cancer care and the multiple available therapeutic modalities make radiation oncology a field in which cost-effectiveness studies could significantly impact healthcare costs and patient care. The purpose of this study was to identify and analyze the published cost-effectiveness research that has focused on radiation therapy. We also aimed to better understand the relative proportions of disease sites studied, modalities compared, and trends over time. Materials/Methods: A PubMed search was performed using the following terms: “cost” and “effectiveness” and “radiation.” A total of 704 articles were identified. Of these studies, 58 specifically analyzed the cost-effectiveness of radiation therapy as definitive treatment or as part of combination therapy. The included studies were analyzed by disease site,
2779 Utilization of Hypofractionation in an Insured Population H.A. Curry1 and R. Jagsi2; 1Eviti Inc., Philadelphia, PA, 2University of Michigan, Ann Arbor, MI Purpose/Objective(s): As the population ages, the prevalence of cancer relative to other diseases is expected to increase, as is the financial burden to patients and society as a whole. Hypofractionation (HF) represents a potential means to decrease economic and indirect burdens associated with the delivery of radiation therapy for many patients. To evaluate the clinical use of HF for patients with either stage I-IIA breast cancer or bone metastases in a working age, insured population, we assessed treatment plans submitted for preauthorization through eviti, Inc’s web-based application. Materials/Methods: A proprietary web-based application enables oncology providers to obtain real time automated precertification for patients insured by payers across the United States that utilize the eviti platform. The platform evaluates treatment plans for consistency with evidence based medicine and compliance with specific payer policies and plan language. All preauthorization requests for radiation treatment submitted during an 18 month period from June 1, 2011-December 7, 2012 were evaluated for the use of HF. HF was defined as daily fraction size >2.5 Gy for breast and >3 Gy for bone metastases. We also evaluated the average cost for delivery of conventionally fractionated treatment vs HF treatment based on average reimbursement rates from three of eviti, Inc.’s largest payers. Results: A total of 3379 cases were submitted of which 279 were bone metastases and 370 were breast. We evaluated the overall rates and within any state with at least 10 submitted plans. Rates of utilization of HF in bone ranged from 0% in IN and MD to 40% in SD. Rates for HF in breast ranged from 0% in FL and OH to 20% in MO. Overall, only 31 of 279 or 11% (95% CI Z 7-15%) of bone metastases plans and 32 of 370 or 9% (95% CI Z 6-12%) of breast plans used HF. Delivery cost of a course of RT for bone metastases was $2,580 for 30 Gy in 10 fractions vs $258 for 8 Gy x 1 vs $1,235 for 20 Gy in 5 fractions. For breast treatment, cost for a typical course of 50 Gy in 25 fractions was $6,451 vs $4,128 for 42.5 Gy in 16 fractions. The cost difference was even greater if IMRT was utilized