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Cost Effectiveness of Prostate Boost with High-Dose Rate Brachytherapy Versus Intensity Modulated Radiation Therapy in the Treatment of Intermediate-High Risk Prostate Cancer
Volume 99 Number 2S Supplement 2017
78 Cost-Effectiveness of Radiation and Chemotherapy for High-Risk Low Grade Glioma Y. Qian,1 S. Maruyama,2 H. Kim,2 E. Pollom,1 K.A. Kumar Jr3 J.P. Harris,4 A.L. Chin,1 A. Pitt,2 E. Bendavid,2 D. Owens,2 B.Y. Durkee,5 and S.G. Soltys1; 1Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, 2Stanford University, Stanford, CA, 3Stanford University School of Medicine, Stanford, CA, 4 Stanford Radiation Oncology, Stanford, CA, 5Stanford Cancer Institute, Stanford, CA Purpose/Objective(s): The standard of care treatment for maximally resected, high risk ( 40 years old or sub-totally resected) low grade glioma (LGG) patients was established by RTOG 9802, which showed an overall survival (OS) of 13.3 years for patients treated with radiotherapy (RT) + PCV (procarbazine, lomustine [CCNU], vincristine) chemotherapy compared to 7.8 years for RT alone. In the era of value-based health care, cost-effectiveness analyses (CEA) have the potential to inform coverage decisions and patient care. To our knowledge, there has been no study assessing the value of RT + PCV as adjuvant therapy for high risk LGG. We sought to analyze the cost-effectiveness of this strategy. Materials/Methods: The base case comprised patients with high risk LGG after maximal safe resection with indications for adjuvant therapy. A decision tree with an integrated three-state Markov model was created to follow patients treated with RT and RT + PCV. Patients existed in one of three health states: stable, progressive, and dead. All patients were assumed to be free of progression at baseline. Survival and freedom from progression were modeled to reflect the results of RTOG 9802 using time-dependent transition probabilities. Health utility values and costs of care were derived from the literature and national registry databases. Starting at initial age of 40 years (median age on RTOG 9802), patients were followed monthly over a maximum time horizon of 60 years after diagnosis (effectively over their remaining lifetimes). Analysis was conducted from the healthcare perspective. Probabilistic sensitivity analysis of modeled parameter distributions was conducted with Monte Carlo simulation of 10,000 samples. Results: Modeled outcomes demonstrated agreement with clinical data in OS, progression free survival (PFS), and expected benefit of addition of PCV to adjuvant RT. In our model, 5-year and 10-year OS rates for RT + PCV vs RT alone were 71.5% vs. 64.8%, and 62.1% vs. 39.2%, respectively; 5-year and 10-year PFS rates for RT + PCV vs RT alone were 61.7% vs. 45.2%, and 50.5% vs. 20.1%, respectively. Patients treated with RT alone accrued 5.17 quality-adjusted life-years (QALYs) (9.63 life-years) at a cost of $139,598. Patients treated with RT+PCV accrued 9.94 QALYs (21.45 life-years) at a cost of $188,234. The addition of PCV to RT yielded an incremental benefit of 4.77 QALYs at an incremental monetary cost of $48,637, leading to an incremental cost-effectiveness ratio of $10,188 per QALY gained. Probabilistic sensitivity analysis demonstrates that costeffectiveness of RT + PCV was insensitive to variations in modeled distributions of input parameters, with 99.96% probability of cost-effectiveness at a willingness-to-pay threshold of $100,000 per QALY. Conclusion: Based on the impressive benefits in outcomes observed in RTOG 9802, the addition of PCV chemotherapy to RT provides high value for cost in the treatment of patients with high-risk low grade glioma. Author Disclosure: Y. Qian: None. S. Maruyama: None. H. Kim: None. E. Pollom: None. K.A. Kumar: None. J.P. Harris: Employee; UCSF. A.L. Chin: None. A. Pitt: None. E. Bendavid: None. D. Owens: None. B.Y. Durkee: None. S.G. Soltys: None.
79 Cost-Effectiveness Analysis of the Oncotype DX Genomic Prostate Score for Guiding Treatment Decisions in Patients With Early Stage Prostate Cancer E.M. Chang, M.L. Steinberg, and A. Raldow; University of California, Los Angeles, Los Angeles, CA
Oral Scientific Sessions
S37
Purpose/Objective(s): The Oncotype DX Genomic Prostate Score (GPS) is a tissue-based 17-gene expression assay that estimates prostate cancer aggressiveness and can be used to inform decisions regarding active surveillance versus immediate treatment. We determined the cost effectiveness of using this test. Materials/Methods: We constructed a Markov model simulating 20-year outcomes for hypothetical 65-year-old men diagnosed with very low-, low-, or intermediate-risk prostate cancer undergoing immediate treatment versus active surveillance with strategies of GPS-guided therapy or no testing. We used utilities, costs, and probabilities of outcomes extracted from the literature and the National Medicare Fee Schedules to determine the incremental cost-effectiveness ratios (ICER) from a payer’s perspective. Costs and outcomes were discounted at 3% annually. We tested the sensitivity of outcomes to uncertainties for key model parameters. Results: In the base case analysis, GPS-guided therapy was associated with $4,107.81 incremental cost and 0.12 quality-adjusted life-year (QALY) gain across all risk groups, which resulted in an ICER of $35,659.09 per QALY gained. When stratified by risk group, the ICER was $32,124.33 per QALY gained in patients with very low risk prostate cancer, $35,653.00 per QALY gained in patients with low risk prostate cancer, and $38,722.42 per QALY gained in patients with intermediate risk prostate cancer. On sensitivity analysis, these findings were robust to variations in the cost of annual management while on active surveillance against willingness-to-pay of $100,000 per QALY. Findings were robust in variations in key model parameters over a wide range of inputs including the probability of exiting active surveillance to treatment, choice of treatment (external beam radiation therapy versus brachytherapy versus prostatectomy), probability of biochemical failure post-treatment, age at diagnosis, and cost of treatment. However, the cost effectiveness of using the GPS was sensitive to small differences of the utility of active surveillance and the utility of no evidence of disease post-treatment. Conclusion: The use of the GPS was cost effective in guiding treatment decisions regarding active surveillance versus immediate treatment across patients with very low-, low-, and intermediate-risk prostate cancer. The cost-effectiveness of using the GPS was sensitive to small differences of the utility of active surveillance, highlighting the importance of engaging patient preferences in this decision. Author Disclosure: E.M. Chang: None. M.L. Steinberg: Honoraria; Accuray. A. Raldow: None.
80 Cost Effectiveness of Prostate Boost with HighDose Rate Brachytherapy Versus Intensity Modulated Radiation Therapy in the Treatment of Intermediate-High Risk Prostate Cancer C.C. Vu,1 K.G. Blas Jr1 T. Lanni Jr,1 G.S. Gustafson,2 and D.J. Krauss1; 1 Beaumont Health, Royal Oak, MI, 2Beaumont Health System - Troy, Sterling Heights, MI Purpose/Objective(s): The recently published ASCENDE-RT randomized clinical trial demonstrated improved biochemical control, albeit with increased toxicity, for a prostate boost with brachytherapy versus external beam radiation therapy alone. Our single-institution retrospective review demonstrated similar findings. It is unknown whether the increased biochemical control of a prostate brachytherapy boost outweighs its increased cost and toxicity. In this study, we investigated the cost-effectiveness of these two modalities in the treatment of intermediate-high risk prostate cancer. Materials/Methods: A multi-state Markov decision tree was created to model a patient with intermediate-high risk prostate cancer. The two treatment options modeled were: (1) 23 fractions of IMRT and 2 fractions of HDR prostate brachytherapy (brachytherapy boost), and (2) 44 fractions of IMRT (IMRT alone). Each patient received 1 year of hormone therapy, per the ASCENDE-RT protocol. Model assumptions, including clinical outcomes, toxicity, and utilities were obtained from the medical literature. Costs were estimated using Medicare reimbursement data. The expected lifetime costs and quality-adjusted life years (QALY) were then estimated.
S38
International Journal of Radiation Oncology Biology Physics
If applicable, an Incremental Cost-Effectiveness Ratio (ICER) was computed. One-way sensitivity analyses were performed over a range of cancer progression rates, utilities, and cost assumptions. We assumed a maximum willingness to pay of $50,000/QALY. Results: The estimated expected lifetime costs of brachytherapy boost were $71,978, compared to $81,543 for IMRT alone. While having a higher upfront cost, brachytherapy boost reduced expected lifetime costs because it decreased the incidence of metastatic castration-resistant prostate cancer (mCRPC), cutting the use of expensive targeted therapy for mCRPC. Brachytherapy boost had an expected QALY of 11.20 years, compared to 9.1 years for IMRT alone. Therefore, brachytherapy boost is a dominant treatment strategy over IMRT alone. One-way sensitivity analyses found brachytherapy boost to be cost-effective over a range of cost, utility, and cancer progression rate assumptions. Conclusion: IMRT with HDR brachytherapy boost is a cost-effective treatment for intermediate-high risk prostate cancer compared to IMRT alone. Author Disclosure: C.C. Vu: None. K.G. Blas: None. T. Lanni: None. G.S. Gustafson: Partnership; Greater Michigan Gamma Knife. Appropriateness Committee, Prostate; ACR. D.J. Krauss: Partnership; Greater Michigan Gamma Knife.
Conclusion: Total one-year costs of care were higher for IMRT compared to non-IMRT, primarily due to higher radiotherapy-specific costs. However, IMRT was associated with significantly decreased costs related to urgent hospitalizations and emergency department visits after treatment, suggesting decreased unplanned health care utilization, which may be due to lower treatment toxicity. Successful development of alternative payment models will require further investigation into the drivers of variation in health care costs. Author Disclosure: A.L. Chin: None. E. Pollom: None. A.C. Koong: None. D.T. Chang: Research Grant; Varian Medical Systems. Honoraria; Varian Medical Systems. Stock; ViewRay.
81 The Impact of IMRT on Health Care Costs Among Elderly Patients with Anal Squamous Cell Carcinoma A.L. Chin, E. Pollom, A.C. Koong, and D.T. Chang; Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA Purpose/Objective(s): The total cost of care related to radiotherapy for the management of anal cancer, as well as drivers of variation in cost, has not been fully elucidated. We examined the impact of intensity-modulated radiotherapy (IMRT) on differences in total, procedure-specific, and patient out-of-pocket costs among Medicare beneficiaries with anal squamous cell carcinoma (SCC). Materials/Methods: We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. We identified 1025 patients with non-metastatic anal SCC diagnosed between 2001 and 2011, treated with chemoradiotherapy, and with continuous Medicare enrollment from one year prior to diagnosis to one year after radiotherapy start. Costs were estimated using Medicare claims data and inflation-adjusted to 2011 dollars. The impact of IMRT on costs was assessed using 1:1 propensity score matched cohort analysis, matching on factors including year of diagnosis, demographic, tumor, and other treatment characteristics. Differences in costs between groups were assessed using two-sided Wilcoxon or Kruskal-Wallis rank sum tests. Results: Among the entire cohort of patients, 405 (39%) received IMRT, with IMRT use increasing over time from 5% in 20012003 to 78% in 2010-2011. Median total health care costs in the year after anal SCC diagnosis increased from $33,682 in 2001-2003 to $47,759 in 2010-2011 (P < 0.001). This corresponded to an increase in median patient out-of-pocket costs from $8,001 to $9,187 over the same time-period (P Z 0.001). Median cost of radiation treatment planning, delivery, and management was $22,414 for IMRT, compared to $11,647 for non-IMRT (P < 0.001). On matched cohort analysis, those who received IMRT had significantly lower costs associated with urgent hospitalizations and emergency department visits in the one-year period after radiotherapy start (median $882 vs $4,880, P Z 0.021). However, one-year total and patient out-of-pocket costs were still higher for those who received IMRT vs non-IMRT (median $36,283 vs $27,165 and $6,970 vs $4,985, respectively, P < 0.001 for each). There were no significant differences in costs associated with intravenous fluid administration or endoscopy procedures, but there was a trend toward higher diagnostic imaging costs for IMRT patients (median $1,636 vs $1,396, P Z 0.093).
82 Spending Among Cancer Patients between ACO and Non-ACO Participants M. Lam,1,2 L.G. Burke,2 J. Zheng,2 and A. Jha2; 1Brigham and Women’s Hospital / Dana Farber Cancer Institute, Boston, MA, 2Harvard T.H. Chan School of Public Health, Boston, MA Purpose/Objective(s): Of the many initiatives aimed at improving the value of healthcare services in the United States, Accountable Care Organizations (ACOs) in particular are receiving substantial policy attention from both sides of the political aisle. Cancer is a common and costly condition with considerable variation in intensity and quality of care delivered. While early evidence from ACOs shows modest reductions in healthcare costs for Medicare beneficiaries overall, we are unaware of any data looking specifically at the impact of ACOs on spending for patients with cancer. Materials/Methods: We studied the 2014 claims of a 20% sample of Medicare fee-for-service (FFS) beneficiaries, age 65 and over who were continuously enrolled, and were age 65 or older. We used ACO assignments of patients by CMS to identify those in an ACO vs not in an ACO. We identified patients with breast, central nervous system, gastrointestinal, gynecologic, head and neck, lung, lymphoma and sarcoma malignancies using ICD9 codes. We identified beneficiary age, race, sex, Medicaid eligibility as an indicator of poverty, and chronic conditions as covariates. We calculated mean annual standardized costs overall as well as stratified by the following categories of spending: inpatient, outpatient, physician, Part D, skilled nursing facility, home health, and hospice. Physician spending was further categorized as follows: evaluation and management, procedures, imaging, durable medical equipment and other. Spending was adjusted for patient characteristics and by chronic conditions, using the Chronic Conditions Warehouse. We repeated our analyses stratified by individual tumor types. Results: Our sample consisted of 913,942 beneficiaries with solid tumors, of whom 21% were in an ACO. ACO beneficiaries had modest but significantly higher total annual standardized costs compared to beneficiaries not in an ACO ($22,576 vs. $21, 484; P < 0.001). The ACO group also had higher inpatient, overall physician spending, skilled nursing facility and home health spending but lower hospice spending compared to non-ACO beneficiaries ($543 vs. $783; P < 0.001). There were no differences between the two groups with respect to Part D ($3,498 vs. $3,542; P Z 0.097) and outpatient spending ($4,452 vs. $4,399; P Z 0.13). When we further stratified physician spending, spending on ACO patients was greater for five out of six categories, with durable medical equipment being the exception. The results were similar when we looked at spending for individual cancers. Conclusion: Standardized total spending among patients with solid cancers treated in an ACO was significantly higher compared to those not in an ACO. This study suggests that ACOs have not yet started targeting cancer care to lower healthcare spending or if they have, they have not yet made much headway. Given that cancer represents a substantially expensive set of conditions, it may be a primary target for future ACO interventions. Author Disclosure: M. Lam: None. L.G. Burke: None. J. Zheng: None. A. Jha: None.
78 Cost-Effectiveness of Radiation and Chemotherapy for High-Risk Low Grade Glioma Y. Qian,1 S. Maruyama,2 H. Kim,2 E. Pollom,1 K.A. Kumar Jr3 J.P. Harris,4 A.L. Chin,1 A. Pitt,2 E. Bendavid,2 D. Owens,2 B.Y. Durkee,5 and S.G. Soltys1; 1Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, 2Stanford University, Stanford, CA, 3Stanford University School of Medicine, Stanford, CA, 4 Stanford Radiation Oncology, Stanford, CA, 5Stanford Cancer Institute, Stanford, CA Purpose/Objective(s): The standard of care treatment for maximally resected, high risk ( 40 years old or sub-totally resected) low grade glioma (LGG) patients was established by RTOG 9802, which showed an overall survival (OS) of 13.3 years for patients treated with radiotherapy (RT) + PCV (procarbazine, lomustine [CCNU], vincristine) chemotherapy compared to 7.8 years for RT alone. In the era of value-based health care, cost-effectiveness analyses (CEA) have the potential to inform coverage decisions and patient care. To our knowledge, there has been no study assessing the value of RT + PCV as adjuvant therapy for high risk LGG. We sought to analyze the cost-effectiveness of this strategy. Materials/Methods: The base case comprised patients with high risk LGG after maximal safe resection with indications for adjuvant therapy. A decision tree with an integrated three-state Markov model was created to follow patients treated with RT and RT + PCV. Patients existed in one of three health states: stable, progressive, and dead. All patients were assumed to be free of progression at baseline. Survival and freedom from progression were modeled to reflect the results of RTOG 9802 using time-dependent transition probabilities. Health utility values and costs of care were derived from the literature and national registry databases. Starting at initial age of 40 years (median age on RTOG 9802), patients were followed monthly over a maximum time horizon of 60 years after diagnosis (effectively over their remaining lifetimes). Analysis was conducted from the healthcare perspective. Probabilistic sensitivity analysis of modeled parameter distributions was conducted with Monte Carlo simulation of 10,000 samples. Results: Modeled outcomes demonstrated agreement with clinical data in OS, progression free survival (PFS), and expected benefit of addition of PCV to adjuvant RT. In our model, 5-year and 10-year OS rates for RT + PCV vs RT alone were 71.5% vs. 64.8%, and 62.1% vs. 39.2%, respectively; 5-year and 10-year PFS rates for RT + PCV vs RT alone were 61.7% vs. 45.2%, and 50.5% vs. 20.1%, respectively. Patients treated with RT alone accrued 5.17 quality-adjusted life-years (QALYs) (9.63 life-years) at a cost of $139,598. Patients treated with RT+PCV accrued 9.94 QALYs (21.45 life-years) at a cost of $188,234. The addition of PCV to RT yielded an incremental benefit of 4.77 QALYs at an incremental monetary cost of $48,637, leading to an incremental cost-effectiveness ratio of $10,188 per QALY gained. Probabilistic sensitivity analysis demonstrates that costeffectiveness of RT + PCV was insensitive to variations in modeled distributions of input parameters, with 99.96% probability of cost-effectiveness at a willingness-to-pay threshold of $100,000 per QALY. Conclusion: Based on the impressive benefits in outcomes observed in RTOG 9802, the addition of PCV chemotherapy to RT provides high value for cost in the treatment of patients with high-risk low grade glioma. Author Disclosure: Y. Qian: None. S. Maruyama: None. H. Kim: None. E. Pollom: None. K.A. Kumar: None. J.P. Harris: Employee; UCSF. A.L. Chin: None. A. Pitt: None. E. Bendavid: None. D. Owens: None. B.Y. Durkee: None. S.G. Soltys: None.
79 Cost-Effectiveness Analysis of the Oncotype DX Genomic Prostate Score for Guiding Treatment Decisions in Patients With Early Stage Prostate Cancer E.M. Chang, M.L. Steinberg, and A. Raldow; University of California, Los Angeles, Los Angeles, CA
Oral Scientific Sessions
S37
Purpose/Objective(s): The Oncotype DX Genomic Prostate Score (GPS) is a tissue-based 17-gene expression assay that estimates prostate cancer aggressiveness and can be used to inform decisions regarding active surveillance versus immediate treatment. We determined the cost effectiveness of using this test. Materials/Methods: We constructed a Markov model simulating 20-year outcomes for hypothetical 65-year-old men diagnosed with very low-, low-, or intermediate-risk prostate cancer undergoing immediate treatment versus active surveillance with strategies of GPS-guided therapy or no testing. We used utilities, costs, and probabilities of outcomes extracted from the literature and the National Medicare Fee Schedules to determine the incremental cost-effectiveness ratios (ICER) from a payer’s perspective. Costs and outcomes were discounted at 3% annually. We tested the sensitivity of outcomes to uncertainties for key model parameters. Results: In the base case analysis, GPS-guided therapy was associated with $4,107.81 incremental cost and 0.12 quality-adjusted life-year (QALY) gain across all risk groups, which resulted in an ICER of $35,659.09 per QALY gained. When stratified by risk group, the ICER was $32,124.33 per QALY gained in patients with very low risk prostate cancer, $35,653.00 per QALY gained in patients with low risk prostate cancer, and $38,722.42 per QALY gained in patients with intermediate risk prostate cancer. On sensitivity analysis, these findings were robust to variations in the cost of annual management while on active surveillance against willingness-to-pay of $100,000 per QALY. Findings were robust in variations in key model parameters over a wide range of inputs including the probability of exiting active surveillance to treatment, choice of treatment (external beam radiation therapy versus brachytherapy versus prostatectomy), probability of biochemical failure post-treatment, age at diagnosis, and cost of treatment. However, the cost effectiveness of using the GPS was sensitive to small differences of the utility of active surveillance and the utility of no evidence of disease post-treatment. Conclusion: The use of the GPS was cost effective in guiding treatment decisions regarding active surveillance versus immediate treatment across patients with very low-, low-, and intermediate-risk prostate cancer. The cost-effectiveness of using the GPS was sensitive to small differences of the utility of active surveillance, highlighting the importance of engaging patient preferences in this decision. Author Disclosure: E.M. Chang: None. M.L. Steinberg: Honoraria; Accuray. A. Raldow: None.
80 Cost Effectiveness of Prostate Boost with HighDose Rate Brachytherapy Versus Intensity Modulated Radiation Therapy in the Treatment of Intermediate-High Risk Prostate Cancer C.C. Vu,1 K.G. Blas Jr1 T. Lanni Jr,1 G.S. Gustafson,2 and D.J. Krauss1; 1 Beaumont Health, Royal Oak, MI, 2Beaumont Health System - Troy, Sterling Heights, MI Purpose/Objective(s): The recently published ASCENDE-RT randomized clinical trial demonstrated improved biochemical control, albeit with increased toxicity, for a prostate boost with brachytherapy versus external beam radiation therapy alone. Our single-institution retrospective review demonstrated similar findings. It is unknown whether the increased biochemical control of a prostate brachytherapy boost outweighs its increased cost and toxicity. In this study, we investigated the cost-effectiveness of these two modalities in the treatment of intermediate-high risk prostate cancer. Materials/Methods: A multi-state Markov decision tree was created to model a patient with intermediate-high risk prostate cancer. The two treatment options modeled were: (1) 23 fractions of IMRT and 2 fractions of HDR prostate brachytherapy (brachytherapy boost), and (2) 44 fractions of IMRT (IMRT alone). Each patient received 1 year of hormone therapy, per the ASCENDE-RT protocol. Model assumptions, including clinical outcomes, toxicity, and utilities were obtained from the medical literature. Costs were estimated using Medicare reimbursement data. The expected lifetime costs and quality-adjusted life years (QALY) were then estimated.
S38
International Journal of Radiation Oncology Biology Physics
If applicable, an Incremental Cost-Effectiveness Ratio (ICER) was computed. One-way sensitivity analyses were performed over a range of cancer progression rates, utilities, and cost assumptions. We assumed a maximum willingness to pay of $50,000/QALY. Results: The estimated expected lifetime costs of brachytherapy boost were $71,978, compared to $81,543 for IMRT alone. While having a higher upfront cost, brachytherapy boost reduced expected lifetime costs because it decreased the incidence of metastatic castration-resistant prostate cancer (mCRPC), cutting the use of expensive targeted therapy for mCRPC. Brachytherapy boost had an expected QALY of 11.20 years, compared to 9.1 years for IMRT alone. Therefore, brachytherapy boost is a dominant treatment strategy over IMRT alone. One-way sensitivity analyses found brachytherapy boost to be cost-effective over a range of cost, utility, and cancer progression rate assumptions. Conclusion: IMRT with HDR brachytherapy boost is a cost-effective treatment for intermediate-high risk prostate cancer compared to IMRT alone. Author Disclosure: C.C. Vu: None. K.G. Blas: None. T. Lanni: None. G.S. Gustafson: Partnership; Greater Michigan Gamma Knife. Appropriateness Committee, Prostate; ACR. D.J. Krauss: Partnership; Greater Michigan Gamma Knife.
Conclusion: Total one-year costs of care were higher for IMRT compared to non-IMRT, primarily due to higher radiotherapy-specific costs. However, IMRT was associated with significantly decreased costs related to urgent hospitalizations and emergency department visits after treatment, suggesting decreased unplanned health care utilization, which may be due to lower treatment toxicity. Successful development of alternative payment models will require further investigation into the drivers of variation in health care costs. Author Disclosure: A.L. Chin: None. E. Pollom: None. A.C. Koong: None. D.T. Chang: Research Grant; Varian Medical Systems. Honoraria; Varian Medical Systems. Stock; ViewRay.
81 The Impact of IMRT on Health Care Costs Among Elderly Patients with Anal Squamous Cell Carcinoma A.L. Chin, E. Pollom, A.C. Koong, and D.T. Chang; Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA Purpose/Objective(s): The total cost of care related to radiotherapy for the management of anal cancer, as well as drivers of variation in cost, has not been fully elucidated. We examined the impact of intensity-modulated radiotherapy (IMRT) on differences in total, procedure-specific, and patient out-of-pocket costs among Medicare beneficiaries with anal squamous cell carcinoma (SCC). Materials/Methods: We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. We identified 1025 patients with non-metastatic anal SCC diagnosed between 2001 and 2011, treated with chemoradiotherapy, and with continuous Medicare enrollment from one year prior to diagnosis to one year after radiotherapy start. Costs were estimated using Medicare claims data and inflation-adjusted to 2011 dollars. The impact of IMRT on costs was assessed using 1:1 propensity score matched cohort analysis, matching on factors including year of diagnosis, demographic, tumor, and other treatment characteristics. Differences in costs between groups were assessed using two-sided Wilcoxon or Kruskal-Wallis rank sum tests. Results: Among the entire cohort of patients, 405 (39%) received IMRT, with IMRT use increasing over time from 5% in 20012003 to 78% in 2010-2011. Median total health care costs in the year after anal SCC diagnosis increased from $33,682 in 2001-2003 to $47,759 in 2010-2011 (P < 0.001). This corresponded to an increase in median patient out-of-pocket costs from $8,001 to $9,187 over the same time-period (P Z 0.001). Median cost of radiation treatment planning, delivery, and management was $22,414 for IMRT, compared to $11,647 for non-IMRT (P < 0.001). On matched cohort analysis, those who received IMRT had significantly lower costs associated with urgent hospitalizations and emergency department visits in the one-year period after radiotherapy start (median $882 vs $4,880, P Z 0.021). However, one-year total and patient out-of-pocket costs were still higher for those who received IMRT vs non-IMRT (median $36,283 vs $27,165 and $6,970 vs $4,985, respectively, P < 0.001 for each). There were no significant differences in costs associated with intravenous fluid administration or endoscopy procedures, but there was a trend toward higher diagnostic imaging costs for IMRT patients (median $1,636 vs $1,396, P Z 0.093).
82 Spending Among Cancer Patients between ACO and Non-ACO Participants M. Lam,1,2 L.G. Burke,2 J. Zheng,2 and A. Jha2; 1Brigham and Women’s Hospital / Dana Farber Cancer Institute, Boston, MA, 2Harvard T.H. Chan School of Public Health, Boston, MA Purpose/Objective(s): Of the many initiatives aimed at improving the value of healthcare services in the United States, Accountable Care Organizations (ACOs) in particular are receiving substantial policy attention from both sides of the political aisle. Cancer is a common and costly condition with considerable variation in intensity and quality of care delivered. While early evidence from ACOs shows modest reductions in healthcare costs for Medicare beneficiaries overall, we are unaware of any data looking specifically at the impact of ACOs on spending for patients with cancer. Materials/Methods: We studied the 2014 claims of a 20% sample of Medicare fee-for-service (FFS) beneficiaries, age 65 and over who were continuously enrolled, and were age 65 or older. We used ACO assignments of patients by CMS to identify those in an ACO vs not in an ACO. We identified patients with breast, central nervous system, gastrointestinal, gynecologic, head and neck, lung, lymphoma and sarcoma malignancies using ICD9 codes. We identified beneficiary age, race, sex, Medicaid eligibility as an indicator of poverty, and chronic conditions as covariates. We calculated mean annual standardized costs overall as well as stratified by the following categories of spending: inpatient, outpatient, physician, Part D, skilled nursing facility, home health, and hospice. Physician spending was further categorized as follows: evaluation and management, procedures, imaging, durable medical equipment and other. Spending was adjusted for patient characteristics and by chronic conditions, using the Chronic Conditions Warehouse. We repeated our analyses stratified by individual tumor types. Results: Our sample consisted of 913,942 beneficiaries with solid tumors, of whom 21% were in an ACO. ACO beneficiaries had modest but significantly higher total annual standardized costs compared to beneficiaries not in an ACO ($22,576 vs. $21, 484; P < 0.001). The ACO group also had higher inpatient, overall physician spending, skilled nursing facility and home health spending but lower hospice spending compared to non-ACO beneficiaries ($543 vs. $783; P < 0.001). There were no differences between the two groups with respect to Part D ($3,498 vs. $3,542; P Z 0.097) and outpatient spending ($4,452 vs. $4,399; P Z 0.13). When we further stratified physician spending, spending on ACO patients was greater for five out of six categories, with durable medical equipment being the exception. The results were similar when we looked at spending for individual cancers. Conclusion: Standardized total spending among patients with solid cancers treated in an ACO was significantly higher compared to those not in an ACO. This study suggests that ACOs have not yet started targeting cancer care to lower healthcare spending or if they have, they have not yet made much headway. Given that cancer represents a substantially expensive set of conditions, it may be a primary target for future ACO interventions. Author Disclosure: M. Lam: None. L.G. Burke: None. J. Zheng: None. A. Jha: None.