Cost-effectiveness analysis of IMRT versus proton therapy for oropharyngeal squamous cell carcinoma

Publication date: Available online 12 April 2018
Source:International Journal of Radiation Oncology*Biology*Physics
Author(s): David J. Sher, Roy B. Tishler, Nhat-Long Pham, Rinaa S. Punglia
PurposeThere has been a strong interest in using intensity-modulated proton beam therapy (PBT) instead of intensity-modulated radiation therapy (IMRT) in the management of stage III-IVB oropharynx cancer (OPC). In this study, we compared the cost-effectiveness of these two modalities.MethodsA Markov model was constructed to compare IMRT with PBT for a 65 year-old patient with stage IVA OPSCC. We assumed PBT led to a 25% reduction in: long-term xerostomia, short-term dysgeusia, and the need for gastrostomy tube. Fewer dental complications were also expected with PBT. Incremental cost-effectiveness ratios (ICERs) were calculated, and value of information (VOI) analyses were performed. The societal willingness-to-pay was defined as $100K/quality-adjusted life year (QALY).ResultsThe ICERs for PBT for favorable HPV-positive OPC were $288,000/QALY, and $390,000/QALY in the payer (PP) and societal (SP) perspectives, respectively. Under nearly every scenario, PBT was not cost-effective, with ICERs above $150,000/QALY in the payer perspective. The ICERs for HPV-negative OPC were typically greater than $250K/QALY in both perspectives. For HPV-positive patients, the ICER was less than $100,000/QALY in the PP only in younger patients who experienced a 50% reduction in both xerostomia and gastrostomy use. On probabilistic sensitivity analyses, there were 0% and 0.4% probabilities that PBT was cost-effective for 65 and 55-year old patients, respectively. The VOI was zero or negligible for all ages and perspectives at WTP of $100,000/QALY and only meaningful in the PP for younger patients at a WTP of $150,000/QALY.ConclusionsPBT was only cost-effective in the PP if assumed to achieve profound reductions in long-term morbidity for younger patients; it was never cost effective in the SP. Prospective data are needed (and may be valuable) to better characterize the comparative toxicities of these treatments but are unlikely to change this calculation, except potentially in the most favorable cohort of patients.

Teaser

This study aimed to determine the cost-effectiveness of IMPT versus IMRT in node-positive oropharynx cancer. We found that IMRT was the cost-effective modality over a wide range of assumptions, many of which were biased in favor of proton therapy. However, IMPT has the potential to be cost-effective for younger patients with a favorable prognosis if its actual quality-of-life benefits are at the extreme ends of superiority over IMRT.


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