Cost-effectiveness Analysis Comparing Conventional, Hypofractionated, and Intraoperative Radiotherapy for Early-Stage Breast Cancer
Cost-effectiveness Analysis Comparing Conventional, Hypofractionated, and Intraoperative Radiotherapy for Early-Stage Breast Cancer
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DOI：
10.1093/jnci/djx068
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发表时间：
2017-11-01
影响因子：
10.3
通讯作者：
Likhacheva, Anna
中科院分区：
文献类型：
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作者：
Deshmukh, Ashish A.;Shirvani, Shervin M.;Likhacheva, Anna
背景：早期乳腺癌是美国医疗保健系统中最普遍和最昂贵的恶性肿瘤之一。乳房肿瘤切除术后的辅助放疗占乳腺癌支出的很大一部分。术中放疗（IORT）和低分割全乳放疗（HF-WBI）等新型放射治疗方法与传统分割全乳放疗（CF-WBI）的相对价值尚不清楚。因此，我们采用前瞻性随机临床试验（rct）收集的结果来比较这些方法的成本效益。方法：我们建立了一个决策分析模型，对接受乳房肿瘤切除术的早期乳腺癌患者进行随访。从磁共振ct中提取复发率、死亡率、并发症率和效用（5年辐射相关生活质量评分）。费用基于医疗保险报销率。从社会和卫生保健部门的角度估计成本效益时考虑了两种情况——第一种假设与辐射相关的负效用在治疗后持续五年，第二种假设负效用停止。使用增量成本-效果比（ICERs）总结终生结局。确定性和概率敏感性分析评估了结果的稳健性。结果：在所有情况下，HF-WBI都优于CF-WBI（即导致更高的质量调整生命年[QALYs]和更低的成本）。与IORT相比，HF-WBI也更有可能产生成本效益；从社会角度来看，假设辐射相关的负效用持续存在，与IORT相比，HF-WBI导致每QALY的ICER为17024美元，在每QALY 10万美元的支付意愿阈值下，成本效益概率为80%。如果假设与辐射相关的负效用停止，ICER较低（11461美元/QALY），导致相对成本效益的可能性更高（83%）。ICER对转移概率和治疗费用最为敏感。结论：对于需要辅助放疗的早期乳腺癌女性，与CF-WBI和IORT相比，HF-WBI更具成本效益。
Background: 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 costeffectiveness of these approaches.Methods: We constructed a decision-analyticmodel 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 fromRCTs. Costs were based on Medicare reimbursement rates. Cost-effectiveness fromsocietal 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.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 costeffectiveness. The ICER was most sensitive to the probability of metastasis and treatment cost.Conclusions: For women with early-stage breast cancer requiring adjuvant radiotherapy, HF-WBI is cost-effective compared with CF-WBI and IORT.