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Cost-Effective Analysis of Hypofractionated Versus Standard 30-Fraction IMRT in Patients With Poor Prognosis Glioblastoma Multiforme
Poster Viewing Abstracts S589
Volume 90 Number 1S Supplement 2014 Author Disclosure: A. Shah: S. Leadership; Member (ASTRO Government Relations Council), Member (ASCO Government Relations Committee). A.K. Jain: None. E.P. Xanthopoulos: None. D. Carrier: None. S.K. Cheng: None. I. Deutsch: None. C. Chao: None.
2961 Cost-Effective Analysis of Hypofractionated Versus Standard 30Fraction IMRT in Patients With Poor Prognosis Glioblastoma Multiforme J.C. Ye,1 M. Yondorf,2 S.C. Pannullo,1 J.A. Boockvar,1 P.E. Stieg,1 T.H. Schwartz,1 R.J. Scheff,1 B. Parashar,1 D. Nori,1 K. Chao,1 and A. Wernicke1; 1New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, 2Weill Cornell Medical College, New York, NY Purpose/Objective(s): We previously reported the tolerability and outcome of hypofractionated radiation therapy (HFRT) using dose painting intensity-modulated radiation therapy (IMRT) 36 Gy and 24 Gy in 6 fractions (fx) every-other-day over 2 weeks with concurrent and adjuvant temozolomide in glioblastoma multiforme (GBM) patients with especially poor prognoses. This study aims to evaluate the cost-effectiveness of radiation therapy (RT) for 6-fx HFRT compared to the standard of 30-fx RT to 60 Gy over 6 weeks, both using IMRT technique. Materials/Methods: The hospital and out-patient charges and reimbursements from Medicare and six major insurance payers for patients with GBM in RTOG RPA Class V who underwent HFRT between 2011 and 2013 were reviewed by the institution’s billing department and compared with GBM patients treated with 30-fx IMRT. Median survival (MS) time for 13 patients undergoing HFRT was defined by the KaplanMeier estimator. Based on the outcome of RPA Class V patients included in the EORTC 26981/22981 trial, MS of 10 months was used as the outcome for 30-fx RT. The reimbursed amounts per patient for each of the treatment modalities were compared using Mann-Whitney U test. Cost effective ratio (CER) and incremental cost-effectiveness ratio (ICER) were calculated for HFRT and 30-fx RT using the median reimbursed amount from the seven payers as a measure of cost-effectiveness. Results: The MS of HFRT patients was not reached at median follow up of 9 months and therefore was estimated to be at least 9 months. The costs of treatments billed per patient were approximately $35,000, resulting in reimbursement of $7,000-25,000 (median $17,000) among the seven payers. The cost billed per patient for 30-fx IMRT was approximately $96,000, resulting in reimbursement of $20,000-71,000 (median $50,000) from the same payers. The lower cost reimbursed for HFRT compared to 30-fx RT was statistically significant (p Z 0.004 by Mann-Whitney U test). CER ($/month gained) for HFRT was $1889/mo while with 30 fx RT was $5000/mo. The ICER for 30 fx RT was similarly calculated to be $33,000, meaning an additional $33,000 was spent on RT alone per patient to improve MS by 1 month from 9 to 10 months, while also putting patients through 24 additional daily RT treatments. Conclusions: In well-selected GBM patients with especially poor prognosis, HFRT may be a more cost-effective therapy compared to standard RT, providing equivalent or near-equivalent outcome with nearly a third of the cost in RT alone and a shorter, more convenient treatment schedule (6 fx in 2 weeks vs 30 fx in 6 weeks) for the patients. Author Disclosure: J.C. Ye: None. M. Yondorf: None. S.C. Pannullo: None. J.A. Boockvar: None. P.E. Stieg: None. T.H. Schwartz: None. R.J. Scheff: None. B. Parashar: None. D. Nori: None. K. Chao: None. A. Wernicke: None.
2962 Development of a Multi parametric Cost-Effectiveness Model for Comparison of Therapeutic Modalities in Definitive Radiation Therapy for Stage III Non-Small Cell Lung Cancer (NSCLC) P. Richard, M. Phillips, J. Zeng, L. Halasz, L. Fang, S. Apisarnthanarax, and R. Rengan; University of Washington, Seattle, WA Purpose/Objective(s): To facilitate a comparative cost-effectiveness analysis of proton beam vs photon beam radiation therapy, we developed a
multi-parametric model allowing for input of patient, disease, treatment, and post-treatment toxicity data using stage III NSCLC as initial proof of principle. Materials/Methods: An influence diagram (ID) was used to model radiation therapy delivery and its acute toxicity. The ID consisted of an action node (protons vs photons), a Bayesian network to calculate the joint probabilities of the parameters, and cost nodes to compute the costs of therapy and toxicities. Radiation costs were calculated from non-facility Medicare reimbursement rates per CPT code. Toxicity costs were based on the national average Medicare reimbursement rates from the Nationwide Inpatient Sample Database for toxicities requiring hospitalization. Results: Input parameters were grouped into three categories: patient-, tumor-, and treatment-specific. Patient factors included age, sex, smoking status, and pre-treatment lung function. Tumor-specific factors included histology, tumor/nodal stage, and location. Treatment-specific factors included chemotherapy type, radiation modality, and established dosevolume parameters for toxicity. Conditional probabilities for photon therapy toxicities were obtained from review of large prospective trials. Proton therapy toxicity probabilities were determined from the largest series of proton therapy in Stage III NSCLC and from published dosevolume models. Toxicity distributions for each input factor were estimated from toxicity meta-analyses for pneumonitis and esophagitis. The overall probability of toxicities was determined for a range of these input parameters. These probabilities are used to calculate the overall cost of treatment (costs of radiation therapy plus costs of intervention for each toxicity grade) across a range of toxicity rates and input parameters. The higher initial costs of proton therapy may be offset by toxicity reduction and its associated costs but depends on the initial assumptions and input parameters of the model. Conclusions: We created a novel, multi-parametric cost-effectiveness model that can examine the overall costs associated with delivering photon and proton radiation for Stage III NSCLC. This model uniquely incorporates pre-treatment and radiation planning parameters, which impacts toxicity and total costs. Through this model, we can obtain population- and patient-specific costs associated with therapy, which should form the basis for investigating the utility or benefits of different modalities in clinical trials or recommending competing treatments for individual patients. Author Disclosure: P. Richard: None. M. Phillips: None. J. Zeng: None. L. Halasz: None. L. Fang: None. S. Apisarnthanarax: None. R. Rengan: None.
2963 Favorable Cost-Effectiveness Is a Hallmark of Modern Hypofractionated Radiation Therapy: The Case of Early-Stage Lung Cancer D.A. Dimitroyannis; New York-Presbyterian, New York, NY Purpose/Objective(s): To demonstrate the cost-effectiveness (superior clinical outcomes with simultaneous lower overall radiation therapy delivery costs) of a hypofractionated treatment for early lung cancer as compared to the conventional fractionation scheme. Materials/Methods: Thirty-two consecutive patients were treated as per RTOG 0236, in standard 3D-conformal technique (3 x 18 Gy) with planning on TPS1 and image-guided delivery on a mainstream, MLC equipped linac1. Detailed logistic records were established from simulation to radiation delivery. The same thirty-two cases were re-planned in volumetric modulated technique on TPS1, TPS2 and TPS3. Image-guided delivery times were measured on linac1 and newer linac2, the latter equipped with finer resolution MLCs and a flattening-filter-free high-dose rate capability. All VMAT treatment plans complied with strict RTOG0236 dosimetric guidelines, in fact exhibiting dosimetric superiority on standard quality indexes, as compared to the 3D conformal, hypofractionated technique. An additional set of conventionally fractionated 3D plans were created on TPS1 for linac1 delivery for overall cost benchmarking. Results: VMAT plans on all three tested planning systems were found to be (i) less cognitive challenging to craft, (ii) dosimetrically non-
Volume 90 Number 1S Supplement 2014 Author Disclosure: A. Shah: S. Leadership; Member (ASTRO Government Relations Council), Member (ASCO Government Relations Committee). A.K. Jain: None. E.P. Xanthopoulos: None. D. Carrier: None. S.K. Cheng: None. I. Deutsch: None. C. Chao: None.
2961 Cost-Effective Analysis of Hypofractionated Versus Standard 30Fraction IMRT in Patients With Poor Prognosis Glioblastoma Multiforme J.C. Ye,1 M. Yondorf,2 S.C. Pannullo,1 J.A. Boockvar,1 P.E. Stieg,1 T.H. Schwartz,1 R.J. Scheff,1 B. Parashar,1 D. Nori,1 K. Chao,1 and A. Wernicke1; 1New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, 2Weill Cornell Medical College, New York, NY Purpose/Objective(s): We previously reported the tolerability and outcome of hypofractionated radiation therapy (HFRT) using dose painting intensity-modulated radiation therapy (IMRT) 36 Gy and 24 Gy in 6 fractions (fx) every-other-day over 2 weeks with concurrent and adjuvant temozolomide in glioblastoma multiforme (GBM) patients with especially poor prognoses. This study aims to evaluate the cost-effectiveness of radiation therapy (RT) for 6-fx HFRT compared to the standard of 30-fx RT to 60 Gy over 6 weeks, both using IMRT technique. Materials/Methods: The hospital and out-patient charges and reimbursements from Medicare and six major insurance payers for patients with GBM in RTOG RPA Class V who underwent HFRT between 2011 and 2013 were reviewed by the institution’s billing department and compared with GBM patients treated with 30-fx IMRT. Median survival (MS) time for 13 patients undergoing HFRT was defined by the KaplanMeier estimator. Based on the outcome of RPA Class V patients included in the EORTC 26981/22981 trial, MS of 10 months was used as the outcome for 30-fx RT. The reimbursed amounts per patient for each of the treatment modalities were compared using Mann-Whitney U test. Cost effective ratio (CER) and incremental cost-effectiveness ratio (ICER) were calculated for HFRT and 30-fx RT using the median reimbursed amount from the seven payers as a measure of cost-effectiveness. Results: The MS of HFRT patients was not reached at median follow up of 9 months and therefore was estimated to be at least 9 months. The costs of treatments billed per patient were approximately $35,000, resulting in reimbursement of $7,000-25,000 (median $17,000) among the seven payers. The cost billed per patient for 30-fx IMRT was approximately $96,000, resulting in reimbursement of $20,000-71,000 (median $50,000) from the same payers. The lower cost reimbursed for HFRT compared to 30-fx RT was statistically significant (p Z 0.004 by Mann-Whitney U test). CER ($/month gained) for HFRT was $1889/mo while with 30 fx RT was $5000/mo. The ICER for 30 fx RT was similarly calculated to be $33,000, meaning an additional $33,000 was spent on RT alone per patient to improve MS by 1 month from 9 to 10 months, while also putting patients through 24 additional daily RT treatments. Conclusions: In well-selected GBM patients with especially poor prognosis, HFRT may be a more cost-effective therapy compared to standard RT, providing equivalent or near-equivalent outcome with nearly a third of the cost in RT alone and a shorter, more convenient treatment schedule (6 fx in 2 weeks vs 30 fx in 6 weeks) for the patients. Author Disclosure: J.C. Ye: None. M. Yondorf: None. S.C. Pannullo: None. J.A. Boockvar: None. P.E. Stieg: None. T.H. Schwartz: None. R.J. Scheff: None. B. Parashar: None. D. Nori: None. K. Chao: None. A. Wernicke: None.
2962 Development of a Multi parametric Cost-Effectiveness Model for Comparison of Therapeutic Modalities in Definitive Radiation Therapy for Stage III Non-Small Cell Lung Cancer (NSCLC) P. Richard, M. Phillips, J. Zeng, L. Halasz, L. Fang, S. Apisarnthanarax, and R. Rengan; University of Washington, Seattle, WA Purpose/Objective(s): To facilitate a comparative cost-effectiveness analysis of proton beam vs photon beam radiation therapy, we developed a
multi-parametric model allowing for input of patient, disease, treatment, and post-treatment toxicity data using stage III NSCLC as initial proof of principle. Materials/Methods: An influence diagram (ID) was used to model radiation therapy delivery and its acute toxicity. The ID consisted of an action node (protons vs photons), a Bayesian network to calculate the joint probabilities of the parameters, and cost nodes to compute the costs of therapy and toxicities. Radiation costs were calculated from non-facility Medicare reimbursement rates per CPT code. Toxicity costs were based on the national average Medicare reimbursement rates from the Nationwide Inpatient Sample Database for toxicities requiring hospitalization. Results: Input parameters were grouped into three categories: patient-, tumor-, and treatment-specific. Patient factors included age, sex, smoking status, and pre-treatment lung function. Tumor-specific factors included histology, tumor/nodal stage, and location. Treatment-specific factors included chemotherapy type, radiation modality, and established dosevolume parameters for toxicity. Conditional probabilities for photon therapy toxicities were obtained from review of large prospective trials. Proton therapy toxicity probabilities were determined from the largest series of proton therapy in Stage III NSCLC and from published dosevolume models. Toxicity distributions for each input factor were estimated from toxicity meta-analyses for pneumonitis and esophagitis. The overall probability of toxicities was determined for a range of these input parameters. These probabilities are used to calculate the overall cost of treatment (costs of radiation therapy plus costs of intervention for each toxicity grade) across a range of toxicity rates and input parameters. The higher initial costs of proton therapy may be offset by toxicity reduction and its associated costs but depends on the initial assumptions and input parameters of the model. Conclusions: We created a novel, multi-parametric cost-effectiveness model that can examine the overall costs associated with delivering photon and proton radiation for Stage III NSCLC. This model uniquely incorporates pre-treatment and radiation planning parameters, which impacts toxicity and total costs. Through this model, we can obtain population- and patient-specific costs associated with therapy, which should form the basis for investigating the utility or benefits of different modalities in clinical trials or recommending competing treatments for individual patients. Author Disclosure: P. Richard: None. M. Phillips: None. J. Zeng: None. L. Halasz: None. L. Fang: None. S. Apisarnthanarax: None. R. Rengan: None.
2963 Favorable Cost-Effectiveness Is a Hallmark of Modern Hypofractionated Radiation Therapy: The Case of Early-Stage Lung Cancer D.A. Dimitroyannis; New York-Presbyterian, New York, NY Purpose/Objective(s): To demonstrate the cost-effectiveness (superior clinical outcomes with simultaneous lower overall radiation therapy delivery costs) of a hypofractionated treatment for early lung cancer as compared to the conventional fractionation scheme. Materials/Methods: Thirty-two consecutive patients were treated as per RTOG 0236, in standard 3D-conformal technique (3 x 18 Gy) with planning on TPS1 and image-guided delivery on a mainstream, MLC equipped linac1. Detailed logistic records were established from simulation to radiation delivery. The same thirty-two cases were re-planned in volumetric modulated technique on TPS1, TPS2 and TPS3. Image-guided delivery times were measured on linac1 and newer linac2, the latter equipped with finer resolution MLCs and a flattening-filter-free high-dose rate capability. All VMAT treatment plans complied with strict RTOG0236 dosimetric guidelines, in fact exhibiting dosimetric superiority on standard quality indexes, as compared to the 3D conformal, hypofractionated technique. An additional set of conventionally fractionated 3D plans were created on TPS1 for linac1 delivery for overall cost benchmarking. Results: VMAT plans on all three tested planning systems were found to be (i) less cognitive challenging to craft, (ii) dosimetrically non-