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Background Bone metastases in the lower spine and pelvis are effectively palliated with radiotherapy (RT), though this can come with side effects such as radiation induced nausea and vomiting (RINV). We hypothesize that high rates of RINV occur in part because of the widespread use of inexpensive simple unplanned palliative radiotherapy (SUPR), over more complex and resource intensive 3D conformal RT, such as volumetric modulated arc therapy (VMAT). Methods This is a randomized, multi-centre phase III trial of SUPR versus VMAT. We will accrue 250 patients to assess the difference in patient-reported RINV. This study is powered to detect a difference in quality of life between patients treated with VMAT vs. SUPR. Discussion This trial will determine if VMAT reduces early toxicity compared to SUPR and may provide justification for this more resource-intensive and costly form of RT. Trial registration Clinicaltrials.gov identifier: NCT03694015 . Date of registration: October 3, 2018.

Background Cost-effectiveness is a pivotal consideration for clinical decision making of high-tech cancer treatment in developing countries. Intensity-modulated proton radiation therapy (IMPT, the advanced form of proton beam therapy) has been found to improve the prognosis of the patients with paranasal sinus and nasal cavity cancers compared with intensity-modulated photon-radiation therapy (IMRT). However, the cost-effectiveness of IMPT has not yet been fully evaluated. This study aimed at evaluating the cost-effectiveness of IMPT versus IMRT for treatment decision making of paranasal sinus and nasal cavity cancers in Chinese settings. Methods A 3-state Markov model was designed for cost-effectiveness analysis. A base case evaluation was performed on a patient of 47-year-old (median age of patients with paranasal sinus and nasal cavity cancers in China). Model robustness was examined by probabilistic sensitivity analysis, Markov cohort analysis and Tornado diagram. Cost-effective scenarios of IMPT were further identified by one-way sensitivity analyses and stratified analyses were performed for different age levels. The outcome measure of the model was the incremental cost-effectiveness ratio (ICER). A strategy was defined as cost-effective if the ICER was below the societal willingness-to-pay (WTP) threshold of China (30,828 US dollars ($) / quality-adjusted life year (QALY)). Results IMPT was identified as being cost-effective for the base case at the WTP of China, providing an extra 1.65 QALYs at an additional cost of $38,928.7 compared with IMRT, and had an ICER of $23,611.2 / QALY. Of note, cost-effective scenarios of IMPT only existed in the following independent conditions: probability of IMPT eradicating cancer ≥0.867; probability of IMRT eradicating cancer ≤0.764; or cost of IMPT ≤ $52,163.9. Stratified analyses for different age levels demonstrated that IMPT was more cost-effective in younger patients than older patients, and was cost-effective only in patients ≤56-year-old. Conclusions Despite initially regarded as bearing high treatment cost, IMPT could still be cost-effective for patients with paranasal sinus and nasal cavity cancers in China. The tumor control superiority of IMPT over IMRT and the patient’s age should be the principal considerations for clinical decision of prescribing this new irradiation technique.

Some urology groups have integrated intensity-modulated radiation therapy (IMRT) into their practice, which allows them to refer patients to their own practice for IMRT. This analysis showed a substantial increase in IMRT use by urologists who acquired ownership of IMRT services. In 2011, nearly 240,900 men in the United States received a new diagnosis of prostate cancer. 1 Approximately 90% of these men had clinically localized disease, which was indolent in most cases. The relative 10-year survival rate among all men with prostate cancer is 98%. 1 , 2 Primary definitive treatments include prostatectomy, external-beam radiation therapy, and brachytherapy. Alternatively, the patient may opt for a less aggressive (monitoring) approach that includes active surveillance or hormone therapy. Table 1 describes each treatment option. Despite substantial variation in reimbursement, evidence suggests that for low-risk disease, the three primary definitive treatments are clinically equivalent when measured in terms . . .

Purpose Hypofractionated short-course radiation therapy (SCRT) is an alternative treatment option for elderly or frail patients with newly diagnosed glioblastoma (GBM) post-surgery. This study compares survival outcomes and treatment costs between patients receiving SCRT and those undergoing standard long-course radiation therapy (LCRT). Methods This retrospective study utilized health insurance claims and national cancer registry data from Korea to compare overall survival (OS) and treatment costs between patients receiving SCRT and LCRT across all ages and sub-group analysis within the subgroup of cases aged 65 and older from 2016 onwards, a period when intensity-modulated radiotherapy (IMRT) was widely adopted. Results A total of 1,598 patients were included. Median OS since the first day of radiation therapy was 10.4 months (95% CI [9.6; 12.8]) for SCRT ( n  = 197) versus 16.2 months (95% CI [15.5; 16.9]) for LCRT ( n  = 1401) respectively. Subgroup analysis using stabilized inverse probability of treatment weighting (S-IPTW) showed indicating non-inferiority in elderly patients in median OS for elderly patients (≥ 65) with 10.6 months (95% CI [8.9; 14.0]) for SCRT ( n  = 147) versus 13.2 months (95% CI [8.9; 14.0]) for LCRT ( n  = 541). The median treatment cost of SCRT is about 6,000 USD lower, 25% less than LCRT. Compliance with the standard TMZ regimen post-radiation improved OS across all age groups. Conclusion Considering comparable OS and shorter treatment duration, SCRT offers a viable, cost-effective option for elderly GBM patients. Adhering to standard TMZ also contributes to OS improvement. Further research reflecting key prognostic factors is essential to refining the role of SCRT.

Purpose This study aimed to determine an appropriate frequency of image‐guided (IG) schedules for left‐sided postmastectomy radiotherapy by comprehensively evaluating dosimetric, radiobiological, imaging dose, and imaging‐related cost outcomes. Methods A retrospective analysis of 20 patients treated with volumetric modulated arc therapy (VMAT) was conducted. Virtual CT images were generated by deforming the pCT to daily cone‐beam computed tomography (CBCT) using deformable image registration. Accumulated dose, tumor control probability (TCP), normal tissue complication probability (NTCP), imaging dose, and imaging‐related cost were compared among six IG schedules: no image‐guided (NIG), weekly image‐guided (WIG), twice‐weekly image‐guided (TIG), thrice‐weekly image‐guided (THRIG), initial 3 days then weekly image‐guided (3D + WIG), and daily image‐guided (DIG). Results Increasing the frequency of IG schedules significantly improved planning target volume (PTV) dose coverage (D95) and TCP (P < 0.001), with DIG achieving optimal target dose delivery. Although no statistically significant differences were observed in dose to organs at risk (OARs) or NTCP, higher‐frequency schedules showed a trend toward reduced variability. However, cumulative imaging dose increased linearly with the frequency of IG schedules (e.g., contralateral breast: 1.26–31.50 mGy; ipsilateral lung: 2.85–71.25 mGy), and imaging‐related cost increased substantially from NIG to DIG, with differences of approximately 1.7‐ to 25‐fold. THRIG demonstrated a favorable balance, with minimal deviations in PTV D95 (1.38%) and TCP (0.83%) relative to DIG, while reducing imaging dose and cost to approximately 60% of DIG. Conclusion While high frequency IG schedules improve target dose coverage, they are associated with increased imaging dose and imaging‐related cost. Within the CBCT‐guided VMAT workflow evaluated in this study, THRIG may provide a balanced trade‐off between treatment precision, safety, and cost.

BackgroundAdvances in radiation technology have transformed treatment options for patients with localized prostate cancer. The evolution of three-dimensional conformal radiation therapy and intensity-modulated radiation therapy (IMRT) have allowed physicians to spare surrounding normal organs and reduce adverse effects. The introduction of proton beam technology and its physical advantage of depositing its energy in tissue at the end-of-range maximum may potentially spare critical organs such as the bladder and rectum in prostate cancer patients. Data thus far are limited to large, observational studies that have not yet demonstrated a definite benefit of protons over conventional treatment with IMRT. The cost of proton beam treatment adds to the controversy within the field.MethodsWe performed an extensive literature review for all proton treatment-related prostate cancer studies. We discuss the history of proton beam technology, as well as its role in the treatment of prostate cancer, associated controversies, novel technology trends, a discussion of cost-effectiveness, and an overview of the ongoing modern large prospective studies that aim to resolve the debate between protons and photons for prostate cancer.ResultsPresent data have demonstrated that proton beam therapy is safe and effective compared with the standard treatment options for prostate cancer. While dosimetric studies suggest lower whole-body radiation dose and a theoretically higher relative biological effectiveness in prostate cancer compared with photons, no studies have demonstrated a clear benefit with protons.ConclusionsEvolving trends in proton treatment delivery and proton center business models are helping to reduce costs. Introduction of existing technology into proton delivery allows further control of organ motion and addressing organs-at-risk. Finally, the much-awaited contemporary studies comparing photon with proton-based treatments, with primary endpoints of patient-reported quality-of-life, will help us understand the differences between proton and photon-based treatments for prostate cancer in the modern era.

High-frequency image-guided radiotherapy (hfIGRT) is ubiquitous but its benefits are unproven. We examined the cost effectiveness of hfIGRT in stage III non-small-cell lung cancer (NSCLC). We selected stage III NSCLC patients [greater than or equal to]66 years old who received definitive radiation therapy from the Surveillance, Epidemiology, and End-Results-Medicare database. Patients were stratified by use of hfIGRT using Medicare claims. Predictors for hfIGRT were calculated using a logistic model. The impact of hfIGRT on lung toxicity free survival (LTFS), esophageal toxicity free survival (ETFS), cancer-specific survival (CSS), overall survival (OS), and cost of treatment was calculated using Cox regressions, propensity score matching, and bootstrap methods. Of the 4,430 patients in our cohort, 963 (22%) received hfIGRT and 3,468 (78%) did not. By 2011, 49% of patients were receiving hfIGRT. Predictors of hfIGRT use included treatment with intensity-modulated radiotherapy (IMRT) (OR = 7.5, p < 0.01), recent diagnosis (OR = 51 in 2011 versus 2006, p < 0.01), and residence in regions where the Medicare intermediary allowed IMRT (OR = 1.50, p < 0.01). hfIGRT had no impact on LTFS (HR 0.97; 95% CI 0.86-1.09), ETFS (HR 1.05; 95% CI 0.93-1.18), CSS (HR 0.94; 95% CI 0.84-1.04), or OS (HR 0.95; 95% CI 0.87-1.04). Mean radiotherapy and total medical costs six months after diagnosis were17,330 versus 15,024 (p < 0.01) and71,569 versus 69,693 (p = 0.49), respectively. hfIGRT did not affect clinical outcomes in elderly patients with stage III NSCLC but did increase radiation cost. hfIGRT deserves further scrutiny through a randomized controlled trial.

Purpose We performed a cost-effectiveness analysis of three strategies for the adjuvant treatment of early breast cancer in women age 70 years or older: an aromatase inhibitor (AI-alone) for 5 years, a 5-fraction course of accelerated partial-breast irradiation using intensity-modulated radiation therapy (APBI-alone), or their combination. Methods We constructed a patient-level Markov microsimulation from the societal perspective. Effectiveness data (local recurrence, distant metastases, survival), and toxicity data were obtained from randomized trials when possible. Costs of side effects were included. Costs were adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALY) were calculated using utilities extracted from the literature. Results The strategy of AI-alone ($12,637) was cheaper than both APBI-alone ($13,799) and combination therapy ($18,012) in the base case. All approaches resulted in similar QALY outcomes (AI-alone 7.775; APBI-alone 7.768; combination 7.807). In the base case, AI-alone was the cost-effective strategy and dominated APBI-alone, while combined therapy was not cost-effective when compared to AI-alone ($171,451/QALY) or APBI-alone ($107,932/QALY). In probabilistic sensitivity analyses, AI-alone was cost-effective at $100,000/QALY in 50% of trials, APBI-alone in 28% and the combination in 22%. Scenario analysis demonstrated that APBI-alone was more effective than AI-alone when AI compliance was lower than 26% at 5 years. Conclusions Based on a Markov microsimulation analysis, both AI-alone and APBI-alone are appropriate options for patients 70 years or older with early breast cancer with small cost differences noted. A prospective trial comparing the approaches is warranted.

In 2013, the American Society for Radiation Oncology (ASTRO) issued a Choosing Wisely recommendation against the routine use of intensity modulated radiotherapy (IMRT) for whole breast irradiation. We evaluated IMRT use and subsequent impact on Medicare expenditure in the period immediately preceding this recommendation to provide a baseline measure of IMRT use and associated cost consequences. SEER records for women ≥66 years with first primary diagnosis of Stage I/II breast cancer (2008-2011) were linked with Medicare claims (2007-2012). Eligibility criteria included lumpectomy within 6 months of diagnosis and radiotherapy within 6 months of lumpectomy. We evaluated IMRT versus conventional radiotherapy (cRT) use overall and by SEER registry (12 sites). We used generalized estimating equations logit models to explore adjusted odds ratios (OR) for associations between clinical, sociodemographic, and health services characteristics and IMRT use. Mean costs were calculated from Medicare allowable costs in the year after diagnosis. Among 13,037 women, mean age was 74.4, 50.5% had left-sided breast cancer, and 19.8% received IMRT. IMRT use varied from 0% to 52% across SEER registries. In multivariable analysis, left-sided breast cancer (OR 1.75), living in a big metropolitan area (OR 2.39), living in a census tract with ≤$90,000 median income (OR 1.75), neutral or favorable local coverage determination (OR 3.86, 1.72, respectively), and free-standing treatment facility (OR 3.49) were associated with receipt of IMRT (p<0.001). Mean expenditure in the year after diagnosis was $8,499 greater (p<0.001) among women receiving IMRT versus cRT. We found highly variable use of IMRT and higher expenditure in the year after diagnosis among women treated with IMRT (vs. cRT) with early-stage breast cancer and Medicare insurance. Our findings suggest a considerable opportunity to reduce treatment variation and cost of care while improving alignment between practice and clinical guidelines.

ABSTRACT This study evaluated the cost-effectiveness of hypofractionated intensity-modulated radiation therapy delivered in 20 fractions (IMRT-20) compared with robot-assisted radical prostatectomy (RARP) for patients with localized low-risk prostate cancer in Japan. A state-transition Markov model was developed from the Japanese healthcare system, using Japanese-specific cost data. Clinical probabilities, adverse event rates and health utility values were primarily derived from international sources, including the ProtecT trial, with extensive sensitivity and scenario analyses to address parameter uncertainty. The base-case analysis compared IMRT-20 and RARP. Scenario analyses included conventional fractionated IMRT (IMRT-38) versus RARP, as well as IMRT-20 versus RARP excluding the utility decrement associated with sexual dysfunction to explore preference-sensitive outcomes. Model outputs included quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefit (INMB). In the base-case analysis, IMRT-20 yielded a modest QALY gain (0.1164) at slightly higher costs compared with RARP, resulting in an ICER of JPY 143 685 per QALY, well below the Japanese willingness-to-pay threshold of JPY 5 000 000 per QALY. Probabilistic sensitivity analysis showed that IMRT-20 was cost effective in 78.1% of simulations. IMRT-38 was less cost effective because of longer treatment duration and higher resource utilization (ICER JPY 3 317 380 per QALY), although it remained below the threshold. When the disutility of sexual dysfunction was excluded, IMRT-20 was dominated by RARP; however, INMB analysis indicated that IMRT-20 became economically favorable when the disutility exceeded 20%. Overall, IMRT-20 represents a clinically and economically efficient definitive treatment strategy for localized low-risk prostate cancer in Japan, supporting value-based cancer care.