Chemotherapy and high–dose-rate brachytherapy in the management of advanced cancers of the nasopharynx

Robotic Radiosurgery vs. Brachytherapy as a Boost to Intensity Modulated Radiotherapy for Tonsillar Fossa and Soft Palate Tumors: The Clinical and Economic Impact of an Emerging Technology

As a basis for making decisions regarding optimal treatment for patients with tonsillar fossa and soft palate tumors, we conducted a preliminary investigation of costs and quality of life (QoL) for two modalities [brachytherapy (BT) and robotic radiosurgery] used to boost radiation to the primary tumors following external beam radiotherapy. BT was well established in our center; a boost by robotic radiosurgery was begun more recently in patients for whom BT was not technically feasible. Robotic radiosurgery boost treatment has the advantage of being non-invasive and is able to reach tumors in cases where there is deep parapharyngeal tumor extension. A neck dissection was performed for patients with nodal-positive disease. Quality of life (pain and difficulty swallowing) was established in long-term follow-up for patients undergoing BT and over a one-year follow-up in robotic radiosurgery patients. Total hospital costs for both groups were computed. Our results show that efficacy and quality of life at one year are comparable for BT and robotic radiosurgery. Total cost for robotic radiosurgery was found to be less than BT primarily due to the elimination of hospital admission and operating room expenses. Confirmation of robotic radiosurgery treatment efficacy and reduced morbidity in the long term requires further study. Quality of life and cost analyses are critical to Health Technology Assessments (HTA). The present study shows how a preliminary HTA of a new medical technology such as robotic radiosurgery with its typical hypofractionation characteristics might be based on short-term clinical outcomes and assumptions of equivalence.

Modern head and neck brachytherapy: from radium towards intensity modulated interventional brachytherapy

Intensity modulated brachytherapy (IMBT) is a modern development of classical interventional radiation therapy (brachytherapy), which allows the application of a high radiation dose sparing severe adverse events, thereby further improving the treatment outcome. Classical indications in head and neck (H&N) cancers are the face, the oral cavity, the naso- and oropharynx, the paranasal sinuses including base of skull, incomplete resections on important structures, and palliation. The application type can be curative, adjuvant or perioperative, as a boost to external beam radiation as well as without external beam radiation and with palliative intention. Due to the frequently used perioperative application method (intraoperative implantation of inactive applicators and postoperative performance of radiation), close interdisciplinary cooperation between surgical specialists (ENT-, dento-maxillary-facial-, neuro- and orbital surgeons), as well interventional radiotherapy (brachytherapy) experts are obligatory. Published results encourage the integration of IMBT into H&N therapy, thereby improving the prognosis and quality of life of patients.

Chest CT and whole-body 18F-FDG PET are cost-effective in screening for distant metastases in head and neck cancer patients

The aim of the study was to define the cost-effectiveness of whole-body (18)F-FDG PET, as compared with chest CT, in screening for distant metastases in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

In a multicenter prospective study, 145 consecutive patients with high risk factors for distant metastases and scheduled for extensive treatment underwent chest CT and whole-body (18)F-FDG PET for screening of distant metastases. The cost data of 80 patients in whom distant metastases developed or who had a follow-up of at least 12 mo were analyzed. Cost-effectiveness analysis, including sensitivity analysis, was performed to compare the results of (18)F-FDG PET, CT, and a combination of CT and (18)F-FDG PET (CT + (18)F-FDG PET).

RESULTS

Pretreatment screening identified distant metastases in 21% of patients. (18)F-FDG PET had a higher sensitivity (53% vs. 37%) and positive predictive value (80% vs. 75%) than did CT. CT + (18)F-FDG PET had the highest sensitivity (63%). The average costs in the CT, (18)F-FDG PET, and CT + (18)F-FDG PET groups amounted to euro38,558 (approximately $57,705), euro38,355 (approximately $57,402), and euro37,954 (approximately $56,801), respectively, in the first year after screening. CT + (18)F-FDG PET resulted in savings between euro203 (approximately $303) and euro604 (approximately $903). Sensitivity analysis showed that the dominance of CT + (18)F-FDG PET was robust.

CONCLUSION

In HNSCC patients with risk factors, pretreatment screening for distant metastases by chest CT is improved by (18)F-FDG PET. The combination of (18)F-FDG PET with CT is the most effective, without leading to additional costs.

A cost and benefit study of esophagectomy for patients with esophageal cancer

INTRODUCTION

The incidence of esophageal cancer is increasing all over the world but the cost-and-benefit of esophagectomy for esophageal cancer patients was rarely studied. The aim of this study is to compare the cost-and-benefit of esophagectomy in different stages of esophageal cancer.

MATERIALS AND METHODS

Clinical and utilization data, including medical expenses and reason for treatment, of esophageal cancer patients were collected, summed and followed up for 5 years. The patients were divided into two groups according to their treatments, with or without esophagectomy. The monthly medical expense and relative expense performance index (REPI) were then calculated. Factors influenced total and monthly medical expense and survival time were further analyzed.

RESULTS

A total of 310 esophageal cancer patients, 281 male and mean age of 64.3, were included in this study. One hundred forty-nine patients had undergone esophagectomy. The 5-year survival rate, total and monthly medical expense for two groups was 36.0% and 10.2% (p<0.001), USD $22,532.8 vs. 12,256.4 (p<0.001) and USD $2,101.65 vs. 2,033.94 (p=0.831), respectively. The REPIs in four different stages were 7.573, 2.422, 2.446 and 0.705. Both esophagectomy and tumor stage were the sole factors that could influence total and monthly medical expense respectively. Both esophagectomy and tumor stage could influence a patient's survival time.

CONCLUSIONS

Esophagectomy has better performance than non-esophagectomy for patients with stages I to III esophageal cancer. Therefore, adding economical considerations, esophagectomy is recommended for patients, at least earlier than stage III.

Longitudinal changes in quality of life and costs in long-term survivors of tumors of the oropharynx treated with brachytherapy or surgery

PURPOSE

Based on earlier studies we were interested in finding out if longitudinal assessment of quality of life (QoL) and costs in long-term survivors of oropharyngeal cancers treated with external beam radiation therapy and brachytherapy (BT) or surgery and postoperative radiotherapy showed a change in QoL over the years. Besides, we were curious to know how much the costs per life year and the QALY would be for this patient group.

METHODS AND MATERIALS

Performance status scales: eating in public, understandability of speech, normalcy of diet, xerostomia and ability to swallow were determined in 2003 and 2005. In 2005, the responses to EORTC QLQ-C30, EORTC H&N35, and the Euroqol questionnaire were also measured. Costs and quality-adjusted life years (QALYs) were calculated.

RESULTS

Eating in public, understandability of speech, and normalcy of diet significantly differed in favor of BT. Surgical patients experienced more speech, teeth, and mouth-opening problems. Mean costs and QALYs for BT were 16,112 euros and 56,060 euros and for surgery 26,590 euros and 93,275 euros, respectively.

CONCLUSIONS

QoL scores don't change over time. Due to the number of admission days, surgery is more costly. Difference in costs for QALYs in favor of BT was observed.

Cancer in the oropharynx: cost calculation of different treatment modalities for controlled primaries, relapses and grade III/IV complications

BACKGROUND AND PURPOSE

This paper presents a model for cost calculation using the different treatment modalities for oropharyngeal (OPh) cancers used in our hospital. We compared full hospital costs, the associated costs of localregional relapses (LRR) and/or treatment related grade III/IV complications.

MATERIALS AND METHODS

Patients with OPh cancer are treated in the Erasmus MC preferably by an organ function preservation protocol. That is, by external beam radiation therapy (EBRT) followed by a brachytherapy (BT) boost, and neck dissection in case of N+ disease (BT-group: 157 patients). If BT is not feasible, resection with postoperative EBRT (S-group [S=Surgery]: 110 patients) or EBRT-alone (EBRT-group: 77 patients) is being pursued. Actuarial localregional control (LRC), disease free survival (DFS) and overall survival (OS) at 5-years were calculated according to the Kaplan-Meier method. The mean costs per treatment group for diagnosis, primary Tx per se, follow-up, (salvage of) locoregional relapse (LRR), distant metastasis (DM), and/or grade III/IV complications needing clinical admission, were computed.

RESULTS

For the BT-, S-, or EBRT treatment groups, LRC rates at 5-years were 85, 82, and 55%, for the DFS, 61, 48, and 43%, and for the OS 65, 52, and 40%, respectively. The mean costs of primary Tx in case of the BT-group is 13,466; for the S-group 24,219, and 12,502 for the EBRT-group. The mean costs of S (the main salvage modality) for a LRR of the BT group or EBRT-group, were 17,861 and 15,887, respectively. The mean costs of clinical management of Grade III/IV complications were 7184 (BT-group), 16,675 (S-group) and 6437 (EBRT-group).

CONCLUSION

The clinical outcome illustrates excellent LRC rates at 5-years for BT (85%), as well as for S (82%). The relatively low 55% LRC rate at 5-years for EBRT probably reflects a negative selection of patients. It is of interest that the total mean costs of patients alive with no evidence of disease is least for the BT-group: 15,101 as opposed to 25,288 (S) and 18,674 (EBRT). Main underlying cause for the high costs with S as opposed to RT alone is the number of associated clinical admission days, not only during primary treatment, but also at relapse. This might be taken into consideration when treating these patients.

Costs of treatment intensification for head and neck cancer: Concomitant chemoradiation randomised for radioprotection with amifostine

This study presents an overview of costs of a chemoradiation protocol in head and neck cancer patients and an analysis of whether prevention of acute toxicity with amifostine results in a reduction to costs. Fifty-four patients treated with weekly paclitaxel concomitant with radiation were randomised for treatment with subcutaneously administered amifostine (500 mg) and analysed with respect to costs of treatment. Total costs for work-up, treatment and toxicity were calculated per treatment arm. No significant differences were found between treatment arms in preliminary results regarding response (98%), toxicity and 2-year survival (77%). Average costs for toxicity were Euro 3.789, largely influenced by hospital admissions (Euro 3.013). Total costs for amifostine administration amounted to Euro 6.495 per patient. The average total costs of treatment were Euro 19.647 versus Euro 13.592 with or without amifostine, respectively. The applied (subcutaneous) dose of amifostine appeared to be insufficient for radioprotection and reduction of related costs in the concomitant chemoradiation scheme, whereas total costs increased remarkably. Although it would be accompanied by a further cost raise, applying a higher amifostine dose might reduce (mucosal) toxicity and therefore in the long run lower related costs for hospital admission and tube feeding.

Cost analysis comparing brachytherapy versus surgery for primary carcinoma of the tonsillar fossa and/or soft palate

PURPOSE

Locoregional control rates, late normal tissue sequelae, and functional outcome scores have not been different for tonsillar fossa and/or soft palate tumors treated by either brachytherapy (BT) or surgery in an organ function preservation protocol. For additional prioritizing in clinical decision-making, we focused on a comparison of the full hospital costs of the different treatment options.

METHODS AND MATERIALS

Between 1986 and 2001, tonsillar fossa and/or soft palate tumors were treated by external beam radiotherapy (EBRT) to the primary tumor and neck, followed by fractionated BT to the primary. Neck dissection (ND) was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, resection combined with postoperative EBRT was executed (surgery group; 86 patients). Locoregional control, disease-free survival, and overall survival were calculated according to the Kaplan-Meier method. The performance status scales, late side effects, and degree of xerostomia have been previously reported. This paper focused on the hospital and follow-up costs for the treatment groups EBRT and BT with or without ND compared with surgery followed by postoperative RT (PORT). Finally, these costs were also computed for future treatment strategies (e.g., better sparing of normal tissues by intensity-modulated RT [IMRT]).

RESULTS

Locoregional control, disease-free survival, and overall survival rate at 5 years for patients treated with EBRT and BT with or without ND vs. surgery plus PORT was 80% vs. 78%, 58% vs. 55%, and 67% vs. 57%, respectively. The major late side effect was xerostomia. Dry mouth syndrome affected the BT group and surgery group equally. The total costs for all treatment groups were 14,262 euro (BT group), 16,628 euro (BT plus ND group), 18,782 euro (surgery plus PORT group), 14,532 euro (IMRT group), and 16,897 euro (IMRT plus ND group).

CONCLUSION

Excellent locoregional tumor control was observed with either modality, with no statistically significant differences in the incidence of the most noted side effect xerostomia. The total costs for BT were less than for surgery: 16,628 euro (19,452 dollars) for EBRT plus BT plus ND vs. 18,782 euro(22,074 dollars) for surgery plus PORT. To reduce the morbidity of xerostomia, we propose further optimizing our organ function preservation protocol by implementing IMRT as a more conformal, tissue-sparing, RT technique. This is of particular interest because the costs of IMRT plus ND (16,897 euro; 19,767 dollars) were not very different from those for BT plus ND (16,628 euro; 19,452 dollars) and were far less than the costs for surgery.