Efficacy and cost of high-frequency IGRT in elderly stage III non-small-cell lung cancer patients.

BACKGROUND: 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). METHODS: We selected stage III NSCLC patients ≥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. RESULTS: 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 were $17,330 versus $15,024 (p < 0.01) and $71,569 versus $69,693 (p = 0.49), respectively. CONCLUSION: 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.

Time-Driven Activity-Based Costing Comparison of Stereotactic Radiosurgery to Multiple Brain Lesions Using Single-Isocenter Versus Multiple-Isocenter Technique.

PURPOSE: Stereotactic radiosurgery (SRS) historically has been used to treat multiple brain lesions using a multiple-isocenter technique-frequently associated with significant complexity in treatment planning and long treatment times. Recently, given innovations in planning algorithms, patients with multiple brain lesions may now be treated with a single-isocenter technique using fewer total arcs and less time spent during image guidance (though with stricter image guided radiation therapy tolerances). This study used time-driven activity-based costing to determine the difference in cost to a provider for delivering SRS to multiple brain lesions using single-isocenter versus multiple-isocenter techniques. METHODS AND MATERIALS: Process maps, consisting of discrete steps, were created for each phase of the SRS care cycle and were based on interviews with department personnel. Actual treatment times (including image guidance) were extracted from treatment record and verify software. Additional sources of data to determine costs included salary/benefit data of personnel and average list price/maintenance costs for equipment. RESULTS: Data were collected for 22 patients who underwent single-isocenter SRS (mean lesions treated, 5.2; mean treatment time, 30.2 minutes) and 51 patients who underwent multiple-isocenter SRS (mean lesions treated, 4.4; mean treatment time, 75.2 minutes). Treatment time for multiple-isocenter SRS varied substantially with increasing number of lesions (11.8 minutes/lesion; P < .001), but to a much lesser degree in single-isocenter SRS (1.8 minutes/lesion; P = .029). The resulting cost savings from single-isocenter SRS based on number of lesions treated ranged from $296 to $3878 for 2 to 10 lesions treated. The 2-mm planning treatment volume margin used with single-isocenter SRS resulted in a mean 43% increase of total volume treated compared with a 1-mm planning treatment volume expansion. CONCLUSIONS: In a comparison of time-driven activity-based costing assessment of single-isocenter versus multiple-isocenter SRS for multiple brain lesions, single-isocenter SRS appears to save time and resources for as few as 2 lesions, with incremental benefits for additional lesions treated.

A Cost-Utility Analysis of Magnetic Resonance (MR) Guided Brachytherapy Versus Two-Dimensional and Computed Tomography (CT) Guided Brachytherapy for Locally Advanced Cervical Cancer.

PURPOSE: The standard treatment for locally advanced cervical cancer is external beam radiation therapy and concurrent cisplatin followed by brachytherapy. Traditionally, 2-dimensional brachytherapy (2DBT) or computed tomography guided brachytherapy (CTgBT) has been used, but magnetic resonance guided brachytherapy (MRgBT) improves clinical outcomes and has become the new standard of care. This cost-utility analysis was undertaken to compare MRgBT to CTgBT and 2DBT. METHODS AND MATERIALS: A Markov model was constructed to evaluate the cost-utility from the perspective of the public health care payer in Ontario. Treatment effectiveness, expressed as quality-adjusted life years, and costs, expressed in 2016 Canadian dollars, were evaluated for MRgBT, CTgBT, and 2DBT. Results were reported as incremental cost-effectiveness ratios for all patients and separately for low and high-risk subgroups. Sensitivity analyses were performed to assess the impact of uncertainty in model parameters. RESULTS: MRgBT improved tumor control, reduced side effects, and was less costly compared with either CTgBT or 2DBT for all patients and in low- and high-risk prognostic subgroups separately. Sensitivity analysis supported the robustness of the findings and identified the cost of treating cancer recurrence to be the single most influential model parameter. CONCLUSIONS: MRgBT is more effective and less costly than CTgBT or 2DBT by avoiding downstream costs of treating cancer recurrence and managing side effects. These findings will assist health care providers and policymakers with future infrastructure and human resource planning to ensure optimal care of women with this disease.

Clinical Evaluation of Onrad, A New Low-cost Version of TomoTherapy that Uses Only Static Beams.

OBJECTIVE: This study evaluated the clinical feasibility of a new low-cost TomoTherapy system (OnradTM) and compared it with low-cost linear accelerator models (linacs). METHODS: Various aspects of treatment and cost were compared between Onrad and linacs for 3-dimensional radiotherapy (3DCRT). Dosimetric comparisons of 10 patients each with breast, stage III lung, prostate, head and neck, and cervical cancers were carried out (total 100 plans). RESULTS: Onrad had advantages in terms of availability of long treatment fields and a smaller mechanical footprint. For breast cancers and lung cancers, target dose homogeneity in Onrad plans was better than that in 3DCRT. In the prostate plans, Onrad plans provided superior D95, conformity and homogeneity. The rectum doses of Onrad plans were lower than those with 3DCRT. Onrad plans provided superior homogeneity and D95 in head and neck cancer. The mean dose and V10-40 Gy of the parotid glands was lower using Onrad. In the cervical cancer plans, target doses were similar with both systems. Normal tissue doses were equal. CONCLUSIONS: Onrad is useful in the clinical setting. Onrad can achieve favorable or comparable dose distributions compared with those of 3DCRT in actual clinical treatment of breast, lung, prostate, head and neck, and cervical cancers.

Variations in Medicaid Payment Rates for Radiation Oncology.

PURPOSE: Interstate variations in Medicaid reimbursements can be significant, and patients who live in states with low Medicaid reimbursements tend to have worse access to care. This analysis describes the extent of variations in Medicaid reimbursements for radiation oncology services across the United States. METHODS AND MATERIALS: The Current Procedural Terminology codes billed for a course of whole breast radiation were identified for this study. Publicly available fee schedules were queried for all 50 states and Washington, DC, to determine the reimbursement for each service and the total reimbursement for the entire episode of care. The degree of interstate payment variation was quantified by computing the range, mean, standard deviation, and coefficient of variation. The cost of care for the entire episode of treatment was compared to the publicly available Kaiser Family Foundation (KFF) Medicaid-to-Medicare fee index to determine if the pattern of payment variation in medical services generally is predictive of the variation seen in radiation oncology specifically. RESULTS: Data were available for 48 states and Washington, DC. The total episode reimbursement (excluding image guidance for respiratory tracking) varied from $2945 to $15,218 (mean, $7233; standard deviation, $2248 or 31%). The correlation coefficient of the KFF index to the calculated entire episode of care for each state was 0.55. CONCLUSIONS: There is considerable variability in coverage and payments rates for radiation oncology services under Medicaid, and these variations track modestly with broader medical fees based on the KFF index. These variations may have implications for access to radiation oncology services that warrant further study.

Performance of a new preloaded fiducial needle to guide radiation therapy of upper gastrointestinal cancers.

BACKGROUND: Insertion of fiducials to outline the targeted lesion allows image-guided radiotherapy, and is best achieved by endoscopic ultrasound (EUS). This study is a performance comparison of the new EUS-guided preloaded fiducial needle against Visicoil fiducials. METHODS: Technical success, visibility score, procedural time, costs, and complications for patients who underwent EUS-guided fiducial placement in upper gastrointestinal malignancies were prospectively collected. RESULTS: 60 patients with upper gastrointestinal cancers had fiducials (14 Visicoil; 46 preloaded fiducials) inserted for image-guided radiotherapy. Technical success was 100 %, with a shorter mean (standard deviation) insertion time of 0.94 minutes (0.28 minutes) vs. 5.5 minutes (1.9 minutes; P < 0.001) and higher visibility score on fluoroscopy of 2 vs. 1.18 (P < 0.001) in the preloaded group. Neither group had major complications related to fiducial insertion. The cost of consumables per patient was lower in the preloaded group at US$480 (US$124) vs. US$643 (US$123; P < 0.001). CONCLUSION: Fiducial insertion for image-guided radiotherapy using the new preloaded needle is associated with 100 % technical success, shorter insertion time, and higher visibility, and is more cost-effective than the Visicoil system.

Imaging Dose, Cancer Risk and Cost Analysis in Image-guided Radiotherapy of Cancers.

The purpose of this retrospective study is to evaluate the cumulative imaging doses, the associated cancer risk and the cost related to the various radiological imaging procedures in image-guided radiotherapy of cancers. Correlations between patients' size and Monte Carlo simulated organ doses were established and validated for various imaging procedures, and then used for patient-specific organ dose estimation of 4,832 cancer patients. The associated cancer risk was estimated with published models and the cost was calculated based on the standard billing codes. The average (range) cumulative imaging doses to the brain, lungs and red bone marrow were 38.0 (0.5-177.3), 18.8 (0.4-246.5), and 49.1 (0.4-274.4) cGy, respectively. The associated average (range) lifetime attributable risk of cancer incidence per 100,000 persons was 78 (0-2798), 271 (1-8948), and 510 (0-4487) for brain cancer, lung cancer and leukemia, respectively. The median (range) imaging cost was $5256 (4268-15896) for the head scans, $5180 (4268-16274) for the thorax scans, and $7080 (4268-15288) for the pelvic scans, respectively. The image-guidance procedures and the accumulated imaging doses should be incorporated into clinical decision-making to personalize radiotherapy for individual patients.

Income generated by women treated with magnetic resonance imaging-based brachytherapy: A simulation study evaluating the macroeconomic benefits of implementing a high-end technology in a public sector healthcare setting.

PURPOSE: To estimate the difference in income generated if all women presenting in our institute over a 5-year period were treated with MRI-based image-guided brachytherapy (MR-IGBT) instead of conventional radiograph-based brachytherapy (CR-BT). METHODS AND MATERIALS: Outcome data from 463 patients (94 treated with MR-IGBT) treated in our institute was used to simulate cumulative women-days of work and cumulative income over 5 years for 5526 patients expected to be treated in this period. The average daily income for a woman was derived from the National Sample Survey Organization (NSSO) survey data. Outcomes from both unmatched and propensity score-matched data sets were simulated. RESULTS: The cumulative income in 5 years ranged between Rs 101-168 million if all patients presenting at our institute underwent MR-IGBT. The simulated excess income ranged from Rs 4-45 million after 5 years, which represented 6-66% of the expenditure incurred for acquiring the required equipment and manpower for practicing exclusive MR-IGBT. CONCLUSIONS: Using outcome data from a prospective cohort of patients treated with MR-IGBT in our institute, we demonstrated that significant economic gains may be realized if MR-IGBT was used instead of CR-BT.

Impact of image guidance during whole-brain radiation therapy.

PURPOSE: Radiation oncologists are rapidly adopting image-guided radiation therapy (IGRT), warranting further evaluation of its role and value. We analyzed the impact of IGRT for one of the most common radiation treatments. METHODS AND MATERIALS: We retrospectively identified patients who received whole-brain radiation therapy (WBRT) with mask immobilization and who underwent routine IGRT with kilovoltage imaging. We calculated IGRT shifts by comparing couch positions before and after imaging. We determined the dosimetric impact of IGRT on lens maximum and dose received by 95% (D95%) of the brain and cribriform region. We calculated episode of care costs using the Medicare Physician Fee Schedule. RESULTS: A total of 206 patients received 2392 image-guided fractions. The median absolute shift was 1 mm, 1 mm, and 2 mm in the vertical, lateral, and longitudinal directions, respectively. Ninety-nine percent of shifts were ≤6 mm, 7 mm, and 9 mm in the vertical, lateral, and longitudinal directions, respectively. For the 22 patients with the largest average shift per fraction, treating without IGRT would have changed D95% brain by a median 3 cGy (interquartile range, 2-9) and D95% cribriform region by a median 39 cGy (interquartile range, 7-116). Without IGRT, lens doses would have increased for 11/22 patients and decreased for 11/22. Using a 700 cGy lens threshold, there was no net change in the proportion of patients above and below the threshold regardless of IGRT use. For a 10-fraction course, daily IGRT accounted for 10% of the total episode of care cost. CONCLUSIONS: IGRT results in small positional corrections during WBRT. Even among cases with the largest shifts, the dosimetric impact is minor for the brain and modest for the cribriform region and lenses. This study suggests mask immobilization alone is sufficient for routine cases, and it may help clinicians make evidence-based decisions about IGRT in this setting.

[A microcost analysis of radiation therapy of localized prostate cancer]. / A prosztatadaganatos betegek sugárterápiájának mikroköltség-számítása.

INTRODUCTION: Development of radiation technology provides new opportunities for the treatment of prostate cancer, but little is known about the costs of novel technologies. AIM: The aim of this analysis was to compare the costs of conventional three-dimensional radiation therapy to normal and hypofractionated intensity-modulated radiation therapy for the treatment of localized prostate cancer. METHOD: The cost-analysis was performed based on the data of a Hungarian oncology center from health care provider's perspective. Irradiation time was assessed from the data of 100 fractions delivered in 20 patients. Unit costs for each component were calculated based on actual costs retrieved from the accounting system of the oncology center. RESULTS: Average treatment delivery times were 14.5 minutes for three-dimensional radiation therapy, 16.2 minutes for intensity-modulated radiation therapy with image-guided and 14 minutes without image-guided method. Expected mean cost of patients undergoing conventional three-dimensional radiation therapy, normal and hypofractionated intensity-modulated radiation therapy were 619 000 HUF, 933 000 HUF and 692 000 HUF, respectively. CONCLUSIONS: Although normal and hypofractionated intensity-modulated radiation therapies have already been proven to be cost-effective, current reimbursement rates do not encourage healthcare providers to use the more effective therapy techniques.

Cost-effectiveness analysis of 3D image-guided brachytherapy compared with 2D brachytherapy in the treatment of locally advanced cervical cancer.

PURPOSE: Three-dimensional image-guided brachytherapy (IGBT) is a significant advance in locally advanced cervical cancer treatment. However, its cost-effectiveness (C/E) is unknown. We performed a C/E analysis of IGBT compared with conventional (two-dimensional [2D]) brachytherapy in the treatment of locally advanced cervical cancer. METHODS AND MATERIALS: A Markov model was constructed to model locally advanced cervical cancer treated with five fractions of high-dose-rate brachytherapy. The model captured clinical parameters, quality of life utility, and treatment costs through the literature review. Costs were 2013 Medicare reimbursement. Strategies were compared using the incremental cost-effectiveness ratio (ICER), and effectiveness was measured in quality-adjusted life-years (QALYs). To account for uncertainty, one-way, two-way, and probabilistic sensitivity analyses were performed. Strategies were evaluated from a payer's perspective with a willingness-to-pay threshold of $50,000/QALY gained. RESULTS: Treatment costs for five fractions of IGBT and 2D brachytherapy were $21,374 and $17,931, respectively. In the base-case analysis, the IGBT strategy costs $3003 more than 2D brachytherapy while gaining 0.16 QALYs, resulting in an ICER of $18,634 per QALY gained. In one-way sensitivity analyses, results were most sensitive to variation of treatment costs, but the ICER remained <$50,000/QALY gained for all cost ranges. Variation of survival, local control, and complication rates was less influential. A probabilistic sensitivity analysis demonstrated that IGBT was favored in 63% of model iterations at a $50,000/QALY gained threshold. CONCLUSION: IGBT for locally advanced cervical cancer is a C/E option compared with 2D brachytherapy. These findings were robust to variation of parameter values supporting the routine use of IGBT in locally advanced cervical cancer.

Comparison of image-guided radiotherapy technologies for prostate cancer.

Radiation oncology has seen a rapid increase in the use of image-guided radiotherapy technology (IGRT) for prostate cancer patients over the past decade. The increase in the use of IGRT is largely driven by the fact that these technologies have been approved by the Food and Drug Administration and are now readily reimbursed by many insurance companies. Prostate cancer patients undergoing intensity modulated radiotherapy (IMRT) now have access to a wide variety of IGRTs that can cost anywhere from $500,000 or more in upfront costs, and can add anywhere from 10 to 15 thousand dollars to a course of IMRT. Some of the IGRT options include daily cone beam computed tomography, ultrasound, orthogonal x-ray units using implanted fiducial markers, implanted radiofrequency markers with the ability to localize and track prostate motion during radiotherapy (Calypso 4D), and cine magnetic resonance imaging. Although these technologies add to the cost of IMRT, there is little direct comparative effectiveness data to help patients, physicians, and policy makers decide if one technology is better than another. In our critical review, the first of its kind, we summarize the advantages, disadvantages, and the limitations of each technology. We also provide an overview of existing literature as it pertains to the comparison of existing IGRTs. Lastly, we provide insights about the need for future outcomes research that may have a significant impact on health policies as it comes to reimbursement in the modern era.

Cost of prostate image-guided radiation therapy: results of a randomized trial.

PURPOSE: This cost analysis aimed to quantify the cost of IGRT in relation to IGRT frequency and modality with Cone Beam Computed Tomography (CBCT) or orthogonal electronic portal imaging with fiducial markers (EPI-FM). MATERIAL AND METHODS: Patients undergoing IGRT for localized prostate cancer were randomized into two prostate control frequencies (daily or weekly). Costs were calculated based on the micro-costing results according to hospitals' perspectives (in Euros, 2009) and the time horizon was radiation therapy. RESULTS: A total of 208 patients were enrolled in seven French cancer centers. A total of 6865 fractions were individually analyzed. The mean total treatment fraction duration was 21.0 min for daily CBCT and 18.3 min for daily EPI-FM. Increasing the control frequency from weekly to daily increased the mean treatment fraction duration by 7.3 min (+53%) for CBCT and 1.7 min (+10%) for EPI-FM (p ≤ 0.01). The mean additional cost per patient of daily controls compared with weekly controls was €679 and €187 for CBCT and EPI-FM, respectively (p<0.0001). CONCLUSIONS: The incremental costs due to different prostate IGRT strategies are relatively moderate, suggesting that daily IGRT combined with intensity-modulated RT (IMRT) could be administered in cases of high-dose radiation delivery to the prostate.

[Prospective economic evaluation of image-guided radiation therapy for prostate cancer in the framework of the national programme for innovative and costly therapies assessment]. / Évaluation économique prospective de la radiothérapie guidée par l'image des cancers de la prostate dans le cadre du programme national de soutien aux thérapeutiques innovantes et coûteuses.

PURPOSE: The main objective of the economical study was to prospectively and randomly assess the additional costs of daily versus weekly patient positioning quality control in image-guided radiotherapy (IGRT), taking into account the modalities of the 3D-imaging: tomography (CBCT) or gold seeds implants. A secondary objective was to prospectively assess the additional costs of 3D versus 2D imaging with portal imaging for patient positioning controls. PATIENTS AND METHODS: Economics data are issued from a multicenter randomized medico-economics trial comparing the two frequencies of patient positioning control during prostate IGRT. A prospective cohort with patient positioning control with PI (control group) was constituted for the cost comparison between 3D (IGRT) versus 2D imaging. The economical evaluation was focused to the radiotherapy direct costs, adopting the hospital's point of view and using a microcosting method applied to the parameters that may lead to cost differences between evaluated strategies. RESULTS: The economical analysis included a total of 241 patients enrolled between 2007 and 2011 in seven centres, 183 in the randomized study (128 with CBCT and 55 with fiducial markers) and 58 in the control group. Compared to weekly controls, the average additional cost per patient of daily controls was €847 (CBCT) and €179 (markers). Compared to PI, the average additional cost per patient was €1392 (CBCT) and €997 (fiducial markers) for daily controls; €545 (CBCT) and €818 (markers) in case of weekly controls. CONCLUSION: A daily frequency for image control in IGRT and 3D images patient positioning control (IGRT) for prostate cancer lead to significant additional cost compared to weekly control and 2D imaging (PI). Long-term clinical assessment will permit to assess the medico-economical ratio of these innovative radiotherapy modalities.

Cost minimisation analysis: kilovoltage imaging with automated repositioning versus electronic portal imaging in image-guided radiotherapy for prostate cancer.

AIMS: To compare the treatment time and cost of prostate cancer fiducial marker image-guided radiotherapy (IGRT) using orthogonal kilovoltage imaging (KVI) and automated couch shifts and orthogonal electronic portal imaging (EPI) and manual couch shifts. MATERIALS AND METHODS: IGRT treatment delivery times were recorded automatically on either unit. Costing was calculated from real costs derived from the implementation of a new radiotherapy centre. To derive cost per minute for EPI and KVI units the total annual setting up and running costs were divided by the total annual working time. The cost per IGRT fraction was calculated by multiplying the cost per minute by the duration of treatment. A sensitivity analysis was conducted to test the robustness of our analysis. Treatment times without couch shift were compared. RESULTS: Time data were analysed for 8648 fractions, 6057 from KVI treatment and 2591 from EPI treatment from a total of 294 patients. The median time for KVI treatment was 6.0 min (interquartile range 5.1-7.4 min) and for EPI treatment it was 10.0 min (interquartile range 8.3-11.8 min) (P value < 0.0001). The cost per fraction for KVI was A$258.79 and for EPI was A$345.50. The cost saving per fraction for KVI varied between A$66.09 and A$101.64 by sensitivity analysis. In patients where no couch shift was made, the median treatment delivery time for EPI was 8.8 min and for KVI was 5.1 min. CONCLUSIONS: Treatment time is less on KVI units compared with EPI units. This is probably due to automation of couch shift and faster evaluation of imaging on KVI units. Annual running costs greatly outweigh initial setting up costs and therefore the cost per fraction was less with KVI, despite higher initial costs. The selection of appropriate IGRT equipment can make IGRT practical within radiotherapy departments.