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Powell A, Batumalai V, Wong K, Kaadan N, Shafiq J, Delaney GP, Vinod SK. Cost-Outcome of Radiotherapy for Local Control and Overall Survival Benefits in Breast Cancer. Clin Oncol (R Coll Radiol) 2024; 36:651-657. [PMID: 39117508 DOI: 10.1016/j.clon.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 06/30/2024] [Accepted: 07/18/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE Radiotherapy (RT) is an integral component in the treatment of breast cancer. The aims of this study were to estimate the cost per 5-year Local Control (LC) and Overall Survival (OS) benefits of the first course of RT, based on breast cancer stage, and the potential cost savings with adoption of the FAST-Forward protocol. METHODS AND MATERIALS All RT activities for breast cancer RT July 2017-June 2020 and their associated costs were consolidated together. The average cost of treatment course was calculated (average cost per fraction X average no. of fractions). Cost per outcome was estimated based on published gains in 5-year LC and OS with optimal use of radiotherapy. RESULTS 481 patients with breast cancer were analysed. The average cost per fraction was $285 AUD (£148 GBP) for all stages. The average costs for 5-year LC and OS gain were $31,483 AUD (£16 392 GBP) and $235,435 AUD (£122 566 GBP) respectively for all stages. The estimated costs for 5-year LC outcomes were $29,675 AUD (£15 450 GBP), $34,675 AUD (£18 053 GBP) and $32,478 AUD (£16 910 GBP) for Stage I-III respectively. The estimated costs for 5-year OS were $455,909 AUD (£237 378 GBP), $532,727 AUD (£ 277 375 GBP) and $60,717 AUD (£31 614 GBP) for Stage I-III respectively. 266 patients had characteristics that made them eligible for the FAST-Forward protocol. A cost saving of $2592-3864 AUD (£1350-2012 GBP) per patient was estimated had these patients been treated with the protocol. CONCLUSIONS The cost of RT for LC outcome is similar across stages. The greatest value for OS outcome was seen in patients with Stage III breast cancer, due to the greater survival benefit with RT in these patients compared with Stage I-II breast cancer. Significant cost savings can be made by implementing the FAST-Forward protocol.
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Affiliation(s)
- A Powell
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia
| | - V Batumalai
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; GenesisCare, Sydney, Australia
| | - K Wong
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Liverpool, NSW
| | - N Kaadan
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - J Shafiq
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Liverpool, NSW
| | - G P Delaney
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Liverpool, NSW
| | - S K Vinod
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, NSW, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Australia; Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Liverpool, NSW.
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Sarria GR, Welzel G, Polednik M, Wenz F, Abo-Madyan Y. Prospective Comparison of Hypofractionated Versus Normofractionated Intensity-Modulated Radiotherapy in Breast Cancer: Late Toxicity Results of the Non-Inferiority KOSIMA Trial (ARO2010-3). Front Oncol 2022; 12:824891. [PMID: 35600361 PMCID: PMC9117716 DOI: 10.3389/fonc.2022.824891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/07/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To compare the late toxicity profile of hypofractionation and normofractionation for whole-breast radiotherapy in breast cancer (BC) patients after conserving surgery. Methods Sixty-year-old or older patients with pTis-pT3, pN0-pN1a, M0 BC were recruited and stratified to hypofractionated (arm R-HF) or normofractionated (arm L-NF) intensity-modulated radiotherapy (IMRT), for right- and left-sided BC, respectively, in this single-center, non-randomized, non-inferiority trial. A boost was allowed if indicated. The primary outcome was the cumulative percentage of patients developing grade III fibrosis, grade I telangiectasia, and/or grade II hyperpigmentation after 2 years, with a pre-specified non-inferiority margin of 15% increase from an expected 2-year toxicity rate of 20%. Results The Median follow-up was 4.93 (0.57-8.65) years for R-HF and 5.02 (0.65-8.72) years for L-NF (p=0.236). The median age was 68 (60-83 and 60-80) years, respectively. In total, 226 patients were recruited (107 for R-HF and 119 for L-NF), with 100 and 117 patients suitable for assessment, respectively. A boost was delivered in 51% and 53% of each arm, respectively. Median PTV volumes were 1013.6 (273-2805) cm3 (R-HF) and 1058.28 (315-2709) cm3 (L-NF, p=0.591). The 2-year primary endpoint rate was 6.1% (95% CI 1.3-11.7, n=5 of 82) and 13.3% (95% CI 7-20.2, n=14 of 105), respectively (absolute difference -7.2%, one-sided 95% CI ∞ to -0.26, favoring R-HF). No local recurrence-free- or overall-survival differences were found. Conclusion In this prospective non-randomized study, hypofractionation did not have higher toxicity than normofractionated whole-breast IMRT.
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Affiliation(s)
- Gustavo R. Sarria
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Radiation Oncology, University Medical Hospital Bonn, University of Bonn, Bonn, Germany
| | - Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martin Polednik
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frederik Wenz
- University Medical Center Freiburg, Medical Faculty Freiburg, Freiburg University, Freiburg, Germany
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Special Considerations in Patients with Early-Stage Breast Cancer and Survivors. Obstet Gynecol Clin North Am 2022; 49:195-208. [DOI: 10.1016/j.ogc.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Sayan M, Yehia ZA, Ohri N, Haffty BG. Hypofractionated Postmastectomy Radiation Therapy. Adv Radiat Oncol 2021; 6:100618. [PMID: 33490735 PMCID: PMC7809517 DOI: 10.1016/j.adro.2020.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/21/2020] [Accepted: 11/09/2020] [Indexed: 02/09/2023] Open
Abstract
Purpose To provide an overview of the major randomized trials that support the use of hypofractionated post-mastectomy radiation therapy for locally advanced breast cancer patients. Methods and Materials PubMed was systematically reviewed for publications reporting use of of hypofractionated radiation therapy in patients requiring post-mastectomy radiation. Results Standard fractionation, which is typically delivered over 5 to 7 weeks, is considered the standard of care in setting of post-mastectomy radiation therapy (PMRT). Modern data has helped to establish hypofractionated whole breast irradiation, which consists of a 3- to 4-week regimen, as a new standard of care for early-stage breast cancer. Hypofractionated whole breast irradiation has also laid the groundwork for the exploration of a hypofractionated approach in the setting of hypofractionated post-mastectomy radiation therapy. Conclusions While standard fractionation remains the most commonly utilized regimen for PMRT, recently published trials support the safety and efficacy of a hypofractionated approach. Ongoing trials are further investigating the use of hypofractionated PMRT.
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Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Zeinab Abou Yehia
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
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Sumodhee S, Pujalte M, Gal J, Cham Kee DL, Gautier M, Schiappa R, Chand ME, Hannoun-Levi JM. Accelerated partial breast irradiation in the elderly: 8-year oncological outcomes and prognostic factors. Brachytherapy 2020; 20:146-154. [PMID: 33132071 DOI: 10.1016/j.brachy.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of the study is to evaluate long-term clinical outcomes and prognostic factors after accelerated partial breast irradiation (APBI) in the elderly using high-dose-rate interstitial multicatheter brachytherapy (HIBT). METHODS AND MATERIALS Between 2005 and 2018, 109 patients underwent APBI using HIBT (34 Gy/10f/5d or 32 Gy/8f/4d). Based on a prospective database, outcomes were retrospectively analyzed (local relapse-free survival, metastatic-free survival, specific survival (SS), and overall survival (OS)). Prognostic factors were investigated. Late toxicity and cosmetic evaluation were reported. RESULTS With a median followup of 97 months [7-159], median age was 81.7 years [58-89]. In accordance with the GEC-ESTRO APBI classification, 72.5%, 11.9%, and 15.6% were classified as low, intermediate, and high risk, respectively. The histological type was mainly invasive ductal carcinoma (87.1%). The median tumor size was 10 mm [range 1-35]. Eight-year local relapse-free survival, SS, and OS were 96.7% [95% confidence interval (CI) [0.923; 1]), 96.7% [95% CI [0.924; 1], and 72% [95% CI [0.616; 0.837], respectively. In univariate analysis, APBI classification was not considered as prognostic factor, whereas molecular classification was prognostic factor for OS (p < 0.0001), SS (p = 0.007), and metastatic-free survival (p = 0.009) but not for local recurrence (p = 0.586). No Grade ≥3 late toxicity was observed, whereas 61 patients (88.4%) and 8 patients (11.6%) presented Grade 1 and 2 toxicities, respectively. The cosmetic outcome was excellent/good for 96.4%. CONCLUSIONS Long-term followup confirms that HIBT is safe and effective for elderly early breast cancer. Our results suggest that selected elderly women presenting with high-risk breast cancer could be also considered for APBI.
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Affiliation(s)
- Shakeel Sumodhee
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France
| | - Marc Pujalte
- Department of Medical Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Jocelyn Gal
- Biostatistics Unit, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Daniel Lam Cham Kee
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France
| | - Mathieu Gautier
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France
| | - Renaud Schiappa
- Department of Medical Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Marie-Eve Chand
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France
| | - Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France.
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Gulstene S, Raziee H. Radiation Boost After Adjuvant Whole Breast Radiotherapy: Does Evidence Support Practice for Close Margin and Altered Fractionation? Front Oncol 2020; 10:772. [PMID: 32670865 PMCID: PMC7332558 DOI: 10.3389/fonc.2020.00772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/21/2020] [Indexed: 12/03/2022] Open
Abstract
Adding a boost to whole breast radiation (WBI) following breast-conserving surgery (BCS) may help improve local control, but it increases the total cost of treatment and may worsen cosmetic outcomes. Therefore, it is reserved for patients whose potential benefit outweighs the risks; however, current evidence is insufficient to support comprehensive and consistent guidance on how to identify these patients, leading to a potential for significant variations in practice. The use of a boost in the setting of close margins and hypofractionated radiotherapy represents two important areas where consensus guidelines, patterns of practice, and current evidence do not seem to converge. Close margins were previously routinely re-excised, but this is no longer felt to be necessary. Because of this recent practice change, good long-term data on the local recurrence risk of close margins with or without a boost is lacking. As for hypofractionation, although there is guidance recommending that the decision to add a boost be independent from the whole-breast fractionation schedule, it appears that patterns-of-practice data may show underutilization of a boost when hypofractionation is used. The use of a boost in these two common clinical scenarios represents important areas of future study for the optimization of adjuvant breast radiation.
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Affiliation(s)
- Stephanie Gulstene
- Department of Radiation Oncology, University of Western Ontario, London, ON, Canada
| | - Hamid Raziee
- Department of Radiation Oncology, BC Cancer Surrey, University of British Columbia, Vancouver, BC, Canada
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Thornhill R, Chang J, Selleck M, Senthil M, Solomon N, Namm JP, Garberoglio CA, Lum S. From Evidence to Practice: Are Low-Risk Breast Cancer Patients still Enduring Unnecessary Costs of Radiation? Am Surg 2020. [DOI: 10.1177/000313481908501240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Radiation is routinely recommended after conservative surgery for breast cancer, despite longstanding Level I evidence showing no survival benefit for elderly patients with favorable disease using endocrine therapy. We sought to evaluate radiation use and costs in patients eligible for omission of radiation. A retrospective single-institution review from 2005 to 2017 was performed of women aged ≥70 years, with cT1N0M0, who were ER/PR positive and HER-2 negative, and receiving breast-conserving surgery. Patient, tumor, and treatment characteristics were compared by use of radiation. Cost estimates used Medicare's 2019 fee schedule. Of 84 patients meeting the study criteria, 72.6 per cent received radiation and 56 per cent received endocrine therapy, with four recurrences (4.9% radiated and 4.4% not radiated, P = 0.9). Early and late grade I radiation toxicities occurred in 67.2 per cent and 26.2 per cent of radiated patients, respectively. Younger age ( P = 0.01), receipt of endocrine therapy ( P < 0.0001), and axillary surgery ( P < 0.0001) were significantly associated with radiation use. There were no significant differences in radiation use based on race/ethnicity, language, comorbidities, BMI, or pathologic tumor size. Estimated total radiation cost was $646,426. Radiation remains overused and endocrine therapy, underused in breast cancer patients eligible to avoid radiation. As gatekeepers for radiation oncology referrals, surgeons can diminish both physical and financial costs of radiation in eligible patients.
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Affiliation(s)
| | - Jenny Chang
- Loma Linda University Health, Loma Linda, California
| | | | | | | | - Jukes P. Namm
- Loma Linda University Health, Loma Linda, California
| | | | - Sharon Lum
- Loma Linda University Health, Loma Linda, California
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Bathily T, Borget I, Rivin Del Campo E, Rivera S, Bourgier C. Partial versus whole breast irradiation: Side effects, patient satisfaction and costs. Cancer Radiother 2019; 23:83-91. [PMID: 30929861 DOI: 10.1016/j.canrad.2018.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/16/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Since accelerated partial breast irradiation has demonstrated non-inferiority to whole breast irradiation regarding recurrence rate in patients with early stage breast cancer, our objective was to compare its impact on short-term adverse events, patient satisfaction and costs. MATERIALS AND METHODS Patients with early stage breast cancer treated by breast-conserving surgery between 2007 and 2012 were included: 48 women who received three-dimensional conformal accelerated partial breast irradiation in a multicentre phase-II trial were paired with 48 patients prospectively treated with whole breast irradiation. Adverse events, and patients' opinions concerning cosmesis, satisfaction and pain, were gathered 1 month after treatment. Direct and indirect costs were collected from the French National Health Insurance System perspective until the end of radiotherapy. RESULTS When comparing its impact, skin reactions occurred in 37% of patients receiving three-dimensional conformal accelerated partial breast radiotherapy and 60% of patients receiving whole breast irradiation (P=0.07); 98% were very satisfied in the group three-dimensional conformal accelerated partial breast radiotherapy versus 46% in the group treated with whole breast irradiation (P<0.001); direct costs were significantly lower in the group treated with partial breast irradiation (mean cost: 2510€ versus 5479€/patient), due to less radiation sessions. CONCLUSION In patients with early-stage breast cancer, partial irradiation offered a good alternative to whole breast irradiation, as it was less expensive and satisfactory. These, and the clinical safety and tolerance results, need to be confirmed by long-term accelerated partial breast irradiation results in on-going phase III trials.
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Affiliation(s)
- T Bathily
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - I Borget
- Service de biostatistique et d'épidémiologie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Inserm U1018, CESP, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Université Paris-Sud, université Paris-Saclay, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - E Rivin Del Campo
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France.
| | - S Rivera
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - C Bourgier
- Department of Radiation Oncology, Institut du cancer de Montpellier, 208, avenue des Apothicaires, 34298 Montpellier, France
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Gupta A, Ohri N, Haffty BG. Hypofractionated radiation treatment in the management of breast cancer. Expert Rev Anticancer Ther 2018; 18:793-803. [PMID: 29902386 DOI: 10.1080/14737140.2018.1489245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The standard treatment for early-stage breast cancer is breast conservation therapy, consisting of breast conserving surgery followed by adjuvant radiation treatment (RT). Conventionally-fractionated whole breast irradiation (CF-WBI) has been the standard RT regimen, but recently shorter courses of hypofractionated whole breast irradiation (HF-WBI) have been advocated for patient convenience and reduction in healthcare costs and resources. Areas covered: This review covers the major randomized European and Canadian trials comparing HF-WBI to CF-WBI with long-term follow-up, as well as additional recently closed randomized trials that further seek to define the applicability of HF-WBI in clinical practice. Randomized data is summarized in terms of clinical utility and for a variety of clinical applications. Recently published consensus guidelines and practical implementation of HF-WBI including its broader effect on the healthcare system are reviewed. Finally, an assessment of the emerging evidence in support of hypofractionation for locally advanced disease is presented. Expert commentary: HF-WBI has replaced CF-WBI as the accepted standard of care in most women with early-stage breast cancer who do not require regional nodal irradiation. Early data supports the continued study of hypofractionation in the locally advanced setting, however broad adoption awaits longer follow-up and additional data from ongoing clinical trials.
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Affiliation(s)
- Apar Gupta
- a Department of Radiation Oncology , Rutgers Cancer Institute of New Jersey , New Brunswick , NJ , USA
| | - Nisha Ohri
- a Department of Radiation Oncology , Rutgers Cancer Institute of New Jersey , New Brunswick , NJ , USA
| | - Bruce G Haffty
- a Department of Radiation Oncology , Rutgers Cancer Institute of New Jersey , New Brunswick , NJ , USA
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Evaluating Candidacy for Hypofractionated Radiation Therapy, Accelerated Partial Breast Irradiation, and Endocrine Therapy After Breast Conserving Surgery. Am J Clin Oncol 2018; 41:526-531. [DOI: 10.1097/coc.0000000000000332] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Balagamwala EH, Manyam BV, Leyrer CM, Karthik N, Smile T, Tendulkar RD, Cherian S, Radford D, Al-Hilli Z, Vicini F, Shah C. Most patients are eligible for an alternative to conventional whole breast irradiation for early-stage breast cancer: A National Cancer Database Analysis. Breast J 2018; 24:806-810. [DOI: 10.1111/tbj.13051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | - Bindu V. Manyam
- Department of Radiation Oncology; Cleveland Clinic; Cleveland OH USA
| | | | - Naveen Karthik
- Department of Radiation Oncology; Cleveland Clinic; Cleveland OH USA
| | - Timothy Smile
- Department of Radiation Oncology; Cleveland Clinic; Cleveland OH USA
| | | | - Sheen Cherian
- Department of Radiation Oncology; Cleveland Clinic; Cleveland OH USA
| | - Diane Radford
- Department of General Surgery; Cleveland Clinic; Cleveland OH USA
| | - Zahraa Al-Hilli
- Department of General Surgery; Cleveland Clinic; Cleveland OH USA
| | - Frank Vicini
- Michigan Healthcare Professionals; Farmington Hills MI USA
| | - Chirag Shah
- Department of Radiation Oncology; Cleveland Clinic; Cleveland OH USA
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12
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Advantages of intraoperative implant for interstitial brachytherapy for accelerated partial breast irradiation either frail patients with early-stage disease or in locally recurrent breast cancer. J Contemp Brachytherapy 2018; 10:97-104. [PMID: 29789758 PMCID: PMC5961524 DOI: 10.5114/jcb.2018.75594] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/13/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose To describe the intraoperative multicatheter implantation technique for accelerated partial breast irradiation (APBI) delivered with high-dose-rate brachytherapy (HDR-BT). Secondarily, to evaluate outcomes and toxicity in a series of 83 patients treated with this technique at our institution. Material and methods Retrospective analysis of a series of patients treated with HDR-BT APBI after intraoperative multicatheter interstitial implant between November 2006 and June 2017 at our institution. We assessed cosmesis, toxicity, overall survival (OS), and disease-free survival (DFS). Results Eighty-three patients were included: 59 patients (71.1%) with primary early-stage breast cancer and 24 (28.9%) with locally recurrent breast cancer. Tumorectomy was performed in all cases, with intraoperative tumor margin assessment and sentinel node biopsy. Median age was 82 years (range, 44-92). The total prescribed dose was 32 Gy (8 treatment fractions) in 60 patients (72.3%), and 34 Gy (10 fractions) in 23 patients (27.7%). Median follow-up was 40 months (range, 1-136 months). Three-year OS and DFS in the recurrent and primary cancer groups were 87% vs. 89%, and 96 % vs. 97.8%, respectively. Five patients died from non-cancer related causes. No local relapses were observed. Rates of acute and late toxicity were low in both groups. The cosmesis was good or excellent in most of patients treated for primary disease; in patients who underwent salvage brachytherapy for local recurrence, cosmesis was good in 49 patients and fair in 6. Conclusions This technique, although time-consuming, achieves good local disease control with a satisfactory toxicity profile in both early-stage and local recurrent breast cancer patients. It may be especially suitable for frail patients.
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Gupta A, Ohri N, Haffty BG. Hypofractionated whole breast irradiation is cost-effective-but is that enough to change practice? Transl Cancer Res 2018; 7:S469-S472. [PMID: 30123739 DOI: 10.21037/tcr.2018.03.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Apar Gupta
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey
| | - Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey
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Monten C, Lievens Y. Adjuvant breast radiotherapy: How to trade-off cost and effectiveness? Radiother Oncol 2017; 126:132-138. [PMID: 29174721 DOI: 10.1016/j.radonc.2017.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 10/30/2017] [Accepted: 11/12/2017] [Indexed: 01/17/2023]
Abstract
INTRODUCTION A series of health economic evaluations (HEE) has analysed the efficiency of new fractionation schedules and techniques for adjuvant breast radiotherapy. This overview assembles the available evidence and evaluates to what extent HEE-results can be compared. METHODS Based on a systematic literature review of HEEs from 1/1/2000 to 30/10/2016, all cost comparison (CC) and cost-effectiveness analyses (CEA) comparing different adjuvant breast radiotherapy approaches were analysed. Costs were extracted and converted to Euro 2016 and costs per QALY were summarized in cost-effectiveness planes. RESULTS Twenty-four publications are withheld, comparing different fractionation schedules and/or irradiation techniques or evaluating the value of adding radiotherapy. Normofractionation and intensity-modulated, interstitial or intraluminal techniques are important cost-drivers. Highest reimbursements are observed in the US, but may overestimate the real cost. Hypofractionation is cost-effective compared to normofractionation, the results of partial breast irradiation are less unequivocal. Intra-operative and external beam approaches seem the most cost-effective for favourable risk groups, but whole breast irradiation is superior in terms of health effect and omission of radiotherapy in terms of costs. CONCLUSION Hypofractionation may be considered the most relevant comparator for new strategies in adjuvant breast radiotherapy, with omission of radiotherapy as an interesting alternative in the very favourable subcategories, especially for partial breast techniques. Although comparison of CC and CEA is hampered by the variability in clinical and economic settings, HEE-based evidence can guide decision-making to tailor-made strategies, allocating the optimal treatment in terms of effectiveness as well as efficiency to the right indication.
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Affiliation(s)
- Chris Monten
- Ghent University Hospital, Radiation Oncology Department, Belgium.
| | - Yolande Lievens
- Ghent University Hospital, Radiation Oncology Department, Belgium
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Monten C, Veldeman L, Verhaeghe N, Lievens Y. A systematic review of health economic evaluation in adjuvant breast radiotherapy: Quality counted by numbers. Radiother Oncol 2017; 125:186-192. [PMID: 28923574 DOI: 10.1016/j.radonc.2017.08.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Evolving practice in adjuvant breast radiotherapy inevitably impacts healthcare budgets. This is reflected in a rise of health economic evaluations (HEE) in this domain. The available HEE literature was analysed qualitatively and quantitatively, using available instruments. METHODS HEEs published between 1/1/2000 and 31/10/2016 were retrieved through a systematic search in Medline, Cochrane and Embase. A quality-assessment using CHEERS (Consolidated Health Economic Evaluation Reporting Standards) was translated into a quantitative score and compared with Tufts Medical Centre CEA registry and Quality of Health Economic Studies (QHES) results. RESULTS Twenty cost-effectiveness analyses (CEA) and thirteen cost comparisons (CC) were analysed. In qualitative evaluation, valuation or justification of data sources, population heterogeneity and discussion on generalizability, in addition to declaration on funding, were often absent or incomplete. After quantification, the average CHEERS-scores were 74% (CI 66.9-81.1%) and 75.6% (CI 70.7-80.5%) for CEAs and CCs respectively. CEA-scores did not differ significantly from Tufts and QHES-scores. CONCLUSION Quantitative CHEERS evaluation is feasible and yields comparable results to validated instruments. HEE in adjuvant breast radiotherapy is of acceptable quality, however, further efforts are needed to improve comprehensive reporting of all data, indispensable for assessing relevance, reliability and generalizability of results.
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Affiliation(s)
- Chris Monten
- Ghent University Hospital, Radiation Oncology Department, Belgium.
| | - Liv Veldeman
- Ghent University Hospital, Radiation Oncology Department, Belgium
| | | | - Yolande Lievens
- Ghent University Hospital, Radiation Oncology Department, Belgium
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16
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Accelerated partial breast irradiation for elderly women with early breast cancer: A compromise between whole breast irradiation and omission of radiotherapy. Brachytherapy 2017; 16:929-934. [DOI: 10.1016/j.brachy.2017.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 05/30/2017] [Accepted: 06/07/2017] [Indexed: 11/18/2022]
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17
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Trifiletti DM, Grover S, Libby B, Showalter TN. Trends in cervical cancer brachytherapy volume suggest case volume is not the primary driver of poor compliance rates with brachytherapy delivery for locally advanced cervical cancer. Brachytherapy 2017; 16:547-551. [DOI: 10.1016/j.brachy.2017.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 01/27/2017] [Accepted: 02/21/2017] [Indexed: 01/29/2023]
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18
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McGuffin M, Merino T, Keller B, Pignol JP. Who Should Bear the Cost of Convenience? A Cost-effectiveness Analysis Comparing External Beam and Brachytherapy Radiotherapy Techniques for Early Stage Breast Cancer. Clin Oncol (R Coll Radiol) 2017; 29:e57-e63. [DOI: 10.1016/j.clon.2016.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 10/27/2016] [Accepted: 11/01/2016] [Indexed: 11/17/2022]
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19
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Hill C, Trifiletti DM, Showalter TN. Failing to deliver established quality treatment for cervical cancer: what is going on and how can we improve it? Future Oncol 2017; 13:299-302. [DOI: 10.2217/fon-2016-0453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Colin Hill
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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20
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Whole breast irradiation vs. APBI using multicatheter brachytherapy in early breast cancer - simulation of treatment costs based on phase 3 trial data. J Contemp Brachytherapy 2016; 8:505-511. [PMID: 28115956 PMCID: PMC5241384 DOI: 10.5114/jcb.2016.64919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/19/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE A recent large phase 3 trial demonstrated that the efficacy of accelerated partial-breast irradiation (APBI) in the treatment of early breast cancer is non-inferior to that of whole breast irradiation (WBI) commonly used in this indication. The aim of this study was to compare the costs of treatment with APBI and WBI in a population of patients after conserving surgery for early breast cancer, and to verify if the use of APBI can result in direct savings of a public payer. MATERIAL AND METHODS The hereby presented cost analysis was based on the results of GEC-ESTRO trial. Expenditures for identified cost centers were estimated on the basis of reimbursement data for the public payer. After determining the average cost of early breast cancer treatment with APBI and WBI over a 5-year period, the variance in this parameter resulting from fluctuations in the price per single procedure was examined on univariate sensitivity analysis. Then, incremental cost-effectiveness ratio (ICER) was calculated to verify the cost against clinical outcome. Finally, a simulation of public payer's expenditures for the treatment of early breast cancer with APBI and WBI in 2013 and 2025 has been conducted. RESULTS The average cost of treatment with APBI is lower than for WBI, even assuming a potential increase in the unit price of the former procedure. There was no additional health benefit of WBI and the calculation of cost-effectiveness was based on the absolute difference in overall local control rate. However, this difference (0.92% vs. 1.44%) was fairly minimal and was not identified as statistically significant during 5 years. CONCLUSIONS The use of APBI as an alternative to WBI in the treatment of early breast cancer would substantially reduce healthcare expenditures in both 2013 and 2025, even assuming an increase in the price per single APBI procedure.
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21
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Rahman F, Seung SJ, Cheng SY, Saherawala H, Earle CC, Mittmann N. Radiation costing methods: a systematic review. ACTA ACUST UNITED AC 2016; 23:e392-408. [PMID: 27536189 DOI: 10.3747/co.23.3073] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Costs for radiation therapy (rt) and the methods used to cost rt are highly diverse across the literature. To date, no study has compared various costing methods in detail. Our objective was to perform a thorough review of the radiation costing literature to identify sources of costs and methods used. METHODS A systematic review of Ovid medline, Ovid oldmedline, embase, Ovid HealthStar, and EconLit from 2005 to 23 March 2015 used search terms such as "radiation," "radiotherapy," "neoplasm," "cost," " cost analysis," and "cost benefit analysis" to locate relevant articles. Original papers were reviewed for detailed costing methods. Cost sources and methods were extracted for papers investigating rt modalities, including three-dimensional conformal rt (3D-crt), intensity-modulated rt (imrt), stereotactic body rt (sbrt), and brachytherapy (bt). All costs were translated into 2014 U.S. dollars. RESULTS Most of the studies (91%) reported in the 33 articles retrieved provided rt costs from the health system perspective. The cost of rt ranged from US$2,687.87 to US$111,900.60 per treatment for imrt, followed by US$5,583.28 to US$90,055 for 3D-crt, US$10,544.22 to US$78,667.40 for bt, and US$6,520.58 to US$19,602.68 for sbrt. Cost drivers were professional or personnel costs and the cost of rt treatment. Most studies did not address the cost of rt equipment (85%) and institutional or facility costs (66%). CONCLUSIONS Costing methods and sources were widely variable across studies, highlighting the need for consistency in the reporting of rt costs. More work to promote comparability and consistency across studies is needed.
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Affiliation(s)
- F Rahman
- Institute for Clinical Evaluative Sciences, ON
| | - S J Seung
- Health Outcomes and Pharmacoeconomics ( hope ) Research Centre, Sunnybrook Research Institute, ON
| | - S Y Cheng
- Institute for Clinical Evaluative Sciences, ON
| | - H Saherawala
- Health Outcomes and Pharmacoeconomics ( hope ) Research Centre, Sunnybrook Research Institute, ON
| | - C C Earle
- Institute for Clinical Evaluative Sciences, ON
| | - N Mittmann
- Cancer Care Ontario, ON.; University of Toronto, ON.; Sunnybrook Research Institute, Toronto, ON
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22
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Han K, Yap ML, Yong JHE, Mittmann N, Hoch JS, Fyles AW, Warde P, Gutierrez E, Lymberiou T, Foxcroft S, Liu FF. Omission of Breast Radiotherapy in Low-risk Luminal A Breast Cancer: Impact on Health Care Costs. Clin Oncol (R Coll Radiol) 2016; 28:587-93. [PMID: 27139262 DOI: 10.1016/j.clon.2016.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 01/08/2023]
Abstract
AIMS The economic burden of cancer care is substantial, including steep increases in costs for breast cancer management. There is mounting evidence that women age ≥ 60 years with grade I/II T1N0 luminal A (ER/PR+, HER2- and Ki67 ≤ 13%) breast cancer have such low local recurrence rates that adjuvant breast radiotherapy might offer limited value. We aimed to determine the total savings to a publicly funded health care system should omission of radiotherapy become standard of care for these patients. MATERIALS AND METHODS The number of women aged ≥ 60 years who received adjuvant radiotherapy for T1N0 ER+ HER2- breast cancer in Ontario was obtained from the provincial cancer agency. The cost of adjuvant breast radiotherapy was estimated through activity-based costing from a public payer perspective. The total saving was calculated by multiplying the estimated number of luminal A cases that received radiotherapy by the cost of radiotherapy minus Ki-67 testing. RESULTS In 2010, 748 women age ≥ 60 years underwent surgery for pT1N0 ER+ HER2- breast cancer; 539 (72%) underwent adjuvant radiotherapy, of whom 329 were estimated to be grade I/II luminal A subtype. The cost of adjuvant breast radiotherapy per case was estimated at $6135.85; the cost of Ki-67 at $114.71. This translated into an annual saving of about $2.0million if radiotherapy was omitted for all low-risk luminal A breast cancer patients in Ontario and $5.1million across Canada. CONCLUSION There will be significant savings to the health care system should omission of radiotherapy become standard practice for women with low-risk luminal A breast cancer.
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Affiliation(s)
- K Han
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - M L Yap
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - J H E Yong
- St. Michael's Hospital, Toronto, Ontario, Canada; Cancer Care Ontario, Toronto, Ontario, Canada
| | - N Mittmann
- HOPE Research Centre, Toronto, Ontario, Canada; Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada
| | - J S Hoch
- St. Michael's Hospital, Toronto, Ontario, Canada; Cancer Care Ontario, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute of Clinical Evaluative Studies, Toronto, Ontario, Canada
| | - A W Fyles
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - P Warde
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Cancer Care Ontario, Toronto, Ontario, Canada
| | - E Gutierrez
- Cancer Care Ontario, Toronto, Ontario, Canada
| | - T Lymberiou
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - S Foxcroft
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - F F Liu
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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23
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Schutzer ME, Arthur DW, Anscher MS. Time-Driven Activity-Based Costing: A Comparative Cost Analysis of Whole-Breast Radiotherapy Versus Balloon-Based Brachytherapy in the Management of Early-Stage Breast Cancer. J Oncol Pract 2016; 12:e584-93. [PMID: 27006360 DOI: 10.1200/jop.2015.008441] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Value in health care is defined as outcomes achieved per dollar spent, and understanding cost is critical to delivering high-value care. Traditional costing methods reflect charges rather than fundamental costs to provide a service. The more rigorous method of time-driven activity-based costing was used to compare cost between whole-breast radiotherapy (WBRT) and accelerated partial-breast irradiation (APBI) using balloon-based brachytherapy. MATERIALS AND METHODS For WBRT (25 fractions with five-fraction boost) and APBI (10 fractions twice daily), process maps were created outlining each activity from consultation to post-treatment follow up. Through staff interviews, time estimates were obtained for each activity. The capacity cost rates (CCR), defined as cost per minute, were calculated for personnel, equipment, and physical space. Total cost was calculated by multiplying the time required of each resource by its CCR. This was then summed and combined with cost of consumable materials. RESULTS The total cost for WBRT was $5,333 and comprised 56% personnel costs and 44% space/equipment costs. For APBI, the total cost was $6,941 (30% higher than WBRT) and comprised 51% personnel costs, 6% space/equipment costs, and 43% consumable materials costs. The attending physician had the highest CCR of all personnel ($4.28/min), and APBI required 24% more attending time than WBRT. The most expensive activity for APBI was balloon placement and for WBRT was computed tomography simulation. CONCLUSION APBI cost more than WBRT when using the dose/fractionation schemes analyzed. Future research should use time-driven activity-based costing to better understand cost with the aim of reducing expenditure and defining bundled payments.
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Affiliation(s)
- Matthew E Schutzer
- Hunter Holmes McGuire Veterans Affairs Medical Center; Virginia Commonwealth University Hospital, Richmond, VA
| | - Douglas W Arthur
- Hunter Holmes McGuire Veterans Affairs Medical Center; Virginia Commonwealth University Hospital, Richmond, VA
| | - Mitchell S Anscher
- Hunter Holmes McGuire Veterans Affairs Medical Center; Virginia Commonwealth University Hospital, Richmond, VA
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24
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Yang JF, Lee MS, Lin CS, Chao HL, Chen CM, Lo CH, Fan CY, Tsao CC, Huang WY. Long-Term Breast Cancer Patient Outcomes After Adjuvant Radiotherapy Using Intensity-Modulated Radiotherapy or Conventional Tangential Radiotherapy. Medicine (Baltimore) 2016; 95:e3113. [PMID: 26986158 PMCID: PMC4839939 DOI: 10.1097/md.0000000000003113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The aim of the article is to analyze breast cancer patient clinical outcomes after long-term follow-up using intensity-modulated radiotherapy (IMRT) or conventional tangential radiotherapy (cRT). We retrospectively reviewed patients with stage 0-III breast cancer who received breast conserving therapy between April 2004 and December 2007. Of the 234 patients, 103 (44%) were treated with IMRT and 131 (56%) were treated with cRT. A total prescription dose of 45 to 50 Gy (1.8-2 Gy per fraction) was delivered to the whole breast. A 14 Gy boost dose was delivered in 7 fractions. The median follow-up was 8.2 years. Five of 131 (3.8%) cRT-treated patients and 2 of 103 (1.9%) IMRT-treated patients had loco-regional failure. The 8-year loco-regional failure-free survival rates were 96.7% and 97.6% (P = 0.393) in the cRT and IMRT groups, respectively, whereas the 8-year disease-free survival (DFS) rates were 91.2% and 93.1%, respectively (P = 0.243). Patients treated with IMRT developed ≥ grade 2 acute dermatitis less frequently than patients treated with cRT (40.8% vs 56.5%; P = 0.017). There were no differences in late toxicity. IMRT reduces ≥ grade 2 acute skin toxicity. Local control, DFS, and overall survival were equivalent with IMRT and cRT. IMRT can be considered a standard technique for breast cancer treatment.
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Affiliation(s)
- Jen-Fu Yang
- From the Department of Radiation Oncology (J-FY, C-SL, H-LC, C-MC, C-HL, C-YF, C-CT, W-YH), Tri-Service General Hospital; School of Public Health (M-SL), National Defense Medical Center; and Institute of Clinical Medicine (W-YH), National Yang-Ming University, Taipei, Taiwan
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25
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Mortimer JW, McLachlan CS, Hansen CJ, Assareh H, Last A, McKay MJ, Shakespeare TP. Use of hypofractionated post-mastectomy radiotherapy reduces health costs by over $2000 per patient: An Australian perspective. J Med Imaging Radiat Oncol 2015; 60:146-53. [PMID: 26511607 DOI: 10.1111/1754-9485.12405] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 09/17/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The most recent clinical practice guidelines released by Cancer Australia draw attention to unanswered questions concerning the health economic considerations associated with hypofractionated radiotherapy. This study aimed to quantify and compare the healthcare costs at a regional Australian radiotherapy institute with respect to conventionally fractionated post-mastectomy radiotherapy (Cf-PMRT) versus hypofractionated post-mastectomy radiotherapy (Hf-PMRT) administration. METHODS Medical records of 196 patients treated with post-mastectomy radiotherapy at the NSW North Coast Cancer Institute from February 2008 to June 2014 were retrospectively reviewed. Australian Medicare item numbers billed for patients receiving either Cf-PMRT of 50 Gy in 25 daily fractions or Hf-PMRT of 40.05 Gy in 15 daily fractions were calculated. Decision tree analysis was used to model costs. Independent-samples t-tests and Mann-Whitney U-tests were used to compare crude average costs for Cf-PMRT and Hf-PMRT and determine which treatment components accounted for any differences. RESULTS Hf-PMRT, with or without irradiation to the regional lymph nodes, was associated with significantly reduced Medicare costs ($5613 AUD per patient for Hf-PMRT vs $8272 AUD per patient for Cf-PMRT; P < 0.001). Savings associated with Hf-PMRT ranged from $1353 (22.1%) for patients receiving no regional irradiation to $2898 (32.0%) for patients receiving both axillary and supraclavicular therapy. CONCLUSIONS Hf-PMRT results in a significant reduction in the financial costs associated with treating breast cancer patients in a regional Australian setting when compared with Cf-PMRT.
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Affiliation(s)
- Joshua W Mortimer
- Rural Clinical School Faculty of Medicine, University of New South Wales, Coffs Harbour, Australia
| | - Craig S McLachlan
- Rural Clinical School Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Carmen J Hansen
- Department of Radiation Oncology, North Coast Cancer Institute, Port Macquarie, Australia
| | - Hassan Assareh
- Rural Clinical School Faculty of Medicine, University of New South Wales, Sydney, Australia.,Epidemiology, Executive Medical Services, Western Sydney Local Health District, Sydney, Australia
| | - Andrew Last
- Department of Radiation Oncology, North Coast Cancer Institute, Port Macquarie, Australia
| | - Michael J McKay
- Department of Radiation Oncology, North Coast Cancer Institute, Lismore, Australia
| | - Thomas P Shakespeare
- Rural Clinical School Faculty of Medicine, University of New South Wales, Coffs Harbour, Australia.,Department of Radiation Oncology, North Coast Cancer Institute, Coffs Harbour, Australia
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26
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Wobb JL, Shah C, Jawad MS, Wallace M, Dilworth JT, Grills IS, Ye H, Chen PY. Comparison of chronic toxicities between brachytherapy-based accelerated partial breast irradiation and whole breast irradiation using intensity modulated radiotherapy. Breast 2015; 24:739-44. [PMID: 26459227 DOI: 10.1016/j.breast.2015.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/21/2015] [Accepted: 09/12/2015] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Brachytherapy-based APBI (bAPBI) shortens treatment duration and limits dose to normal tissue. While studies have demonstrated similar local control when comparing bAPBI and whole breast irradiation using intensity modulated radiotherapy (WBI-IMRT), comparison of late side effects is limited. Here, we report chronic toxicity profiles associated with these two treatment modalities. METHODS 1034 patients with early stage breast cancer were treated at a single institution; 489 received standard-fractionation WBI-IMRT between 2000 and 2013 and 545 received bAPBI (interstitial 40%, applicator-based 60%) between 1993 and 2013. Chronic toxicity was evaluated ≥6 months utilizing CTCAE version 3.0; cosmesis was evaluated using the Harvard scale. RESULTS Median follow-up was 4.6 years (range 0.1-13.4) for WBI-IMRT versus 6.7 years (range 0.1-20.1) for bAPBI (p < 0.001). Compared to WBI-IMRT, bAPBI was associated with higher rates of ≥grade 2 seroma formation (14.4% vs 2.9%, p < 0.001), telangiectasia (12.3% vs 2.1%, p = 0.002) and symptomatic fat necrosis (10.2% vs 3.6%, p < 0.001). Lower rates of hyperpigmentation were observed (5.8% vs 14.5%; p = 0.001). Infection rates were similar (3.3% vs 1.3%, p = 0.07). There was no difference between rates of fair (6.1% vs. 4.1%, p = 0.30) or poor (0.2% vs. 0.5%, p = NS) cosmesis. Mastectomy rates for local recurrence (3.1% for WBI-IMRT and 1.2% for bAPBI, p = 0.06), or for other reasons (0.8% and 0.6%, p = 0.60) were similar between groups. CONCLUSION With 5-year follow-up, WBI-IMRT and bAPBI are associated with similar, acceptable rates of toxicity. These data further support the utilization of bAPBI as a modality to deliver adjuvant radiation in a safe and efficacious manner.
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Affiliation(s)
- Jessica L Wobb
- Dept of Radiation Oncology, Arthur G. James Hospital/Ohio State Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Chirag Shah
- Cleveland Clinic, Dept of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH, USA
| | - Maha S Jawad
- Dept of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Michelle Wallace
- Dept of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Joshua T Dilworth
- Dept of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Inga S Grills
- Dept of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Hong Ye
- Dept of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Peter Y Chen
- Dept of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
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27
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Smith GL, Huo J, Giordano SH, Hunt KK, Buchholz TA, Smith BD. Utilization and Outcomes of Breast Brachytherapy in Younger Women. Int J Radiat Oncol Biol Phys 2015; 93:91-101. [PMID: 26279027 DOI: 10.1016/j.ijrobp.2015.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/09/2015] [Accepted: 05/08/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE To directly compare (1) radiation treatment utilization patterns; (2) risks of subsequent mastectomy; and (3) costs of radiation treatment in patients treated with brachytherapy versus whole-breast irradiation (WBI), in a national, contemporary cohort of women with incident breast cancer, aged 64 years and younger. METHODS AND MATERIALS Using MarketScan health care claims data, we identified 45,884 invasive breast cancer patients (aged 18-64 years), treated from 2003 to 2010 with lumpectomy, followed by brachytherapy (n = 3134) or whole-breast irradiation (n = 42,750). We stratified patients into risk groups according to age (Age < 50 vs Age ≥ 50) and endocrine therapy status (Endocrine- vs Endocrine+). "Endocrine+" patients filled an endocrine therapy prescription within 1 year after lumpectomy. Pathologic hormone receptor status was not available in this dataset. In brachytherapy versus WBI patients, utilization trends and 5-year subsequent mastectomy risks were compared. Stratified, adjusted subsequent mastectomy risks were calculated using proportional hazards regression. RESULTS Brachytherapy utilization increased from 2003 to 2010: in patients Age < 50, from 0.6% to 4.9%; patients Age ≥ 50 from 2.2% to 11.3%; Endocrine- patients, 1.3% to 9.4%; Endocrine+ patients, 1.9% to 9.7%. Age influenced treatment selection more than endocrine status: 17% of brachytherapy patients were Age < 50 versus 32% of WBI patients (P < .001); whereas 41% of brachytherapy patients were Endocrine-versus 44% of WBI patients (P = .003). Highest absolute 5-year subsequent mastectomy risks occurred in Endocrine-/Age < 50 patients (24.4% after brachytherapy vs 9.0% after WBI (hazard ratio [HR] 2.18, 95% confidence interval [CI] 1.37-3.47); intermediate risks in Endocrine-/Age ≥ 50 patients (8.6% vs 4.9%; HR 1.76, 95% CI 1.26-2.46); and lowest risks in Endocrine+ patients of any age: Endocrine+/Age < 50 (5.5% vs 4.5%; HR 1.18, 95% CI 0.61-2.31); Endocrine+/Age ≥ 50 (4.2% vs 2.4%; HR 1.71, 95% CI 1.16-2.51). CONCLUSION In this younger cohort, endocrine status was a valuable discriminatory factor predicting subsequent mastectomy risk after brachytherapy versus WBI and therefore may be useful for selecting appropriate younger brachytherapy candidates.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jinhai Huo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Buchholz
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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28
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Marta GN, Macedo CR, Carvalho HDA, Hanna SA, da Silva JLF, Riera R. Accelerated partial irradiation for breast cancer: systematic review and meta-analysis of 8653 women in eight randomized trials. Radiother Oncol 2014; 114:42-9. [PMID: 25480094 DOI: 10.1016/j.radonc.2014.11.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Accelerated partial breast irradiation (APBI) is the strategy that allows adjuvant treatment delivery in a shorter period of time in smaller volumes. This study was undertaken to assess the effectiveness and outcomes of APBI in breast cancer compared with whole-breast irradiation (WBI). MATERIAL AND METHODS Systematic review and meta-analysis of randomized controlled trials of WBI versus APBI. Two authors independently selected and assessed the studies regarding eligibility criteria. RESULTS Eight studies were selected. A total of 8653 patients were randomly assigned for WBI versus APBI. Six studies reported local recurrence outcomes. Two studies were matched in 5 years and only one study for different time of follow-up. Meta-analysis of two trials assessing 1407 participants showed significant difference in the WBI versus APBI group regarding the 5-year local recurrence rate (HR=4.54, 95% CI: 1.78-11.61, p=0.002). Significant difference in favor of WBI for different follow-up times was also found. No differences in nodal recurrence, systemic recurrence, overall survival and mortality rates were observed. CONCLUSIONS APBI is associated with higher local recurrence compared to WBI without compromising other clinical outcomes.
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Affiliation(s)
- Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil; Department of Radiation Oncology, Instituto do Câncer de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, Brazil.
| | - Cristiane Rufino Macedo
- Brazilian Cochrane Center and Discipline of Emergency Medicine and Evidence-Based Medicine, Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), Brazil.
| | - Heloisa de Andrade Carvalho
- Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil; Department of Radiation Oncology, Instituto de Radiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
| | | | | | - Rachel Riera
- Brazilian Cochrane Center and Discipline of Emergency Medicine and Evidence-Based Medicine, Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), Brazil.
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Montero A, Sanz X, Hernanz R, Cabrera D, Arenas M, Bayo E, Moreno F, Algara M. Accelerated hypofractionated breast radiotherapy: FAQs (Frequently Asked Questions) and facts. Breast 2014; 23:299-309. [DOI: 10.1016/j.breast.2014.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 01/14/2014] [Accepted: 01/19/2014] [Indexed: 10/25/2022] Open
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Hassett MJ, Elkin EB. What does breast cancer treatment cost and what is it worth? Hematol Oncol Clin North Am 2014; 27:829-41, ix. [PMID: 23915747 DOI: 10.1016/j.hoc.2013.05.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The costs of breast cancer care are substantial and growing, and they extend across the spectrum of care. Medical therapies and hospitalizations account for a significant proportion of these costs. Cost-effectiveness analysis (CEA) is the preferred method for assessing the health benefits of medical interventions relative to their costs. Although many CEAs have been conducted for a wide range of breast cancer treatments, these analyses are not used routinely to guide coverage or utilization decisions in the United States. Currently, patients and providers may not consider costs when making most treatment decisions; this is likely to change as payment reform spreads.
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Affiliation(s)
- Michael J Hassett
- Department of Medicine, Harvard Medical School, 250 Longwood Avenue, Boston, MA 02115, USA.
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Shah C, Lanni TB, Saini H, Nanavati A, Wilkinson JB, Badiyan S, Vicini F. Cost-efficacy of acceleration partial-breast irradiation compared with whole-breast irradiation. Breast Cancer Res Treat 2013; 138:127-35. [PMID: 23329353 DOI: 10.1007/s10549-013-2412-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 01/09/2013] [Indexed: 01/19/2023]
Abstract
The purpose of this study was to analyze the cost-efficacy of multiple accelerated partial-breast irradiation (APBI) techniques compared with whole breast irradiation (WBI) delivered utilizing 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiation therapy (IMRT). A previously reported matched-pair analysis consisting of 199 patients receiving WBI and 199 patients receiving interstitial APBI formed the basis of this analysis. Cost analyses included a cost minimization analysis, incremental cost- effectiveness ratio (ICER) analysis, and cost per quality adjusted life year (QALY) analysis. Per 1,000 patients treated, the cost savings with the utilization of APBI compared to WBI IMRT is $14.9 million, $10.9 million, $8.8 million, $5.0 million, and $9.7 million for APBI 3D-CRT, APBI IMRT, APBI single-lumen (SL), APBI multi-lumen (ML), and APBI interstitial, respectively. Per 1,000 patients treated, the cost savings with the utilization of APBI compared to WBI 3D-CRT is $6.0 million, $2.0 million, and $0.7 million for APBI 3D-CRT, APBI IMRT, and APBI interstitial, respectively. The cost per QALY for APBI SL, APBI ML, and APBI interstitial compared with APBI 3D-CRT are $12,273, $66,032, and $546, respectively. When incorporating non-medical costs and cost of recurrences the cost per QALY was $54,698 and $49,009 for APBI ML compared with APBI 3D-CRT. When compared to WBI IMRT, all APBI techniques are cost-effective based on cost minimization, ICER, and QALY analyses. When compared to WBI 3D-CRT, external beam APBI techniques represent a more cost-effective approach based on cost minimization with brachytherapy representing a cost-effective approach based on cost per QALY.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63108, USA.
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