Division of Genetics and Development, Toronto Western Research Institute, Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada M5T 2S8. email@example.com
Neoplastic metastatic epidural spinal cord compression is a common complication of cancer that causes pain and progressive neurologic impairment. The previous standard treatment for this condition involved corticosteroids and radiotherapy (RT). Direct decompressive surgery with postoperative radiotherapy (S + RT) is now increasingly being chosen by clinicians to significantly improve patients' ability to walk and reduce their need for opioid analgesics and corticosteroids. A cost-utility analysis was conducted to compare S + RT with RT alone based on the landmark randomized clinical trial by Patchell et al. (2005). It was performed from the perspective of the Ontario Ministry of Health and Long-Term Care. Ontario-based costs were adjusted to 2010 US dollars. S + RT is more costly but also more effective than corticosteroids and RT alone, with an incremental cost-effectiveness ratio of US$250 307 per quality-adjusted life year (QALY) gained. First order probabilistic sensitivity analysis revealed that the probability of S + RT being cost-effective is 18.11%. The cost-effectiveness acceptability curve showed that there is a 91.11% probability of S + RT being cost-effective over RT alone at a willingness-to-pay of US$1 683 000 per QALY. In practice, the results of our study indicate that, by adopting the S + RT strategy, there would still be a chance of 18.11% of not paying extra at a willingness-to-pay of US$50 000 per QALY. Those results are sensitive to the costs of hospice palliative care. Our results suggest that adopting a standard S + RT approach for patients with MSCC is likely to increase health care costs but would result in improved outcomes.
Cites: Int J Radiat Oncol Biol Phys. 2006 Nov 15;66(4):1212-817145536
Cites: Br J Cancer. 2006 Feb 27;94(4):486-9116434993
Cites: N Engl J Med. 1992 Aug 27;327(9):614-91296600
Cites: JAMA. 1996 Oct 16;276(15):1253-88849754
Cites: JAMA. 1996 Oct 23-30;276(16):1339-418861994
Cites: Med Decis Making. 1997 Apr-Jun;17(2):126-359107607
Cites: Med Decis Making. 1997 Apr-Jun;17(2):136-419107608
Cites: Med Decis Making. 1997 Apr-Jun;17(2):152-99107610
Basal cell carcinoma (BCC) is the most common human malignancy and accounts for over 60,000 new cases of cancer in Canada annually. Although expensive to the health care system, no Canadian studies have reported the costs involved in management. This study calculated the costs of managing high-risk BCCs using radiotherapy (RT) and Mohs micrographic surgery (MMS).
Forty-nine consecutive complex BCC cases presenting to a skin cancer referral center were collected prospectively. All were located on the head and neck and were either recurrent disease or located in "at risk" sites such as the eye, ear, lip, or nose. All patients underwent MMS. A radiation oncologist reviewed each case retrospectively. The costs of MMS were the actual costs of the procedure, with an additional amount added to account for the technical costs of the surgery. The costs of RT included physician fees and technical fees. A sensitivity analysis was performed using known recurrence rates from the medical literature.
Five patients were excluded from the comparative analysis because radiation was not recommended (age 1 year, these did not reach significance within our sample size. Despite the limitation that treatment costs may be center and provincially dependent, we hope this preliminary report will initiate further study into comparing Canadian costs of managing skin cancer.
To compute cost-effectiveness/cost-utility (CE/CU) ratios, from the treatment clinic and societal perspectives, for high-dose palliative radiotherapy treatment (RT) for advanced non-small-cell lung cancer (NSCLC) against best supportive care (BSC) as comparator, and thereby demonstrate a method for computing CE/CU ratios when randomized clinical trial (RCT) data cannot be generated.
Unit cost estimates based on an earlier reported 1989-90 analysis of treatment costs at the Vancouver Island Cancer Centre, Victoria, British Columbia, Canada, are updated to 1997-1998 and then used to compute the incremental cost of an average dose of high-dose palliative RT. The incremental number of life days and quality-adjusted life days (QALDs) attributable to treatment are from earlier reported regression analyses of the survival and quality-of-life data from patients who enrolled prospectively in a lung cancer management cost-effectiveness study at the clinic over a 2-year period from 1990 to 1992.
The baseline CE and CU ratios are $9245 Cdn per life year (LY) and $12,836 per quality-adjusted life year (QALY), respectively, from the clinic perspective; and $12,253/LY and $17,012/QALY, respectively, from the societal perspective. Multivariate sensitivity analysis for the CE ratio produces a range of $5513-28,270/LY from the clinic perspective, and $7307-37,465/LY from the societal perspective. Similar calculations for the CU ratio produce a range of $7205-37, 134/QALY from the clinic perspective, and $9550-49,213/QALY from the societal perspective.
The cost effectiveness and cost utility of high-dose palliative RT for advanced NSCLC compares favorably with the cost effectiveness of other forms of treatment for NSCLC, of treatments of other forms of cancer, and of many other commonly used medical interventions; and lies within the US $50, 000/QALY benchmark often cited for cost-effective care.
PURPOSE: The Swedish Rectal Cancer Trial (SRCT) demonstrated that a short-term regimen of high-dose fractionated preoperative radiotherapy (5 x 5 Gy) reduced the local recurrence rates and improved overall survival. This has had an impact on the primary treatment of rectal cancer. The current study investigated the cost-effectiveness of the new combined approach. METHODS AND MATERIALS: After an 8-year follow-up, in-hospital and outpatient costs related to the treatment of rectal cancer and its complications were analyzed for 98 randomly allocated patients who participated in the SRCT from a single Swedish health care region. The costs were then related to the clinical data from the SRCT regarding complications, local and distant recurrences, and survival. RESULTS: The total cost for a nonirradiated patient was US$30,080 compared with US$35,268 for an irradiated patient. The surgery-alone group had increased costs related to local recurrences, and the radiotherapy group had increased costs for irradiation and complications. With a survival benefit of 21 months (retrieved from the SRCT), the cost for a saved year was US$3654. Sensitivity analyses for different rates of local recurrences, the costs related to complications and less marked survival benefit showed that this figure could vary up to US$15,228. CONCLUSION: The cost for a life-year saved in these data was US$3654. This figure could reach US$15,228 in the most pessimistic setting of the sensitivity tests, a cost still comparable with other well-accepted medical interventions.
A recent randomized clinical trial has demonstrated that direct decompressive surgery plus radiotherapy was superior to radiotherapy alone for the treatment of metastatic epidural spinal cord compression. The current study compared the cost-effectiveness of the two approaches.
In the original clinical trial, clinical effectiveness was measured by ambulation and survival time until death. In this study, an incremental cost-effectiveness analysis was performed from a societal perspective. Costs related to treatment and posttreatment care were estimated and extended to the lifetime of the cohort. Weibull regression was applied to extrapolate outcomes in the presence of censored clinical effectiveness data.
From a societal perspective, the baseline incremental cost-effectiveness ratio (ICER) was found to be $60 per additional day of ambulation (all costs in 2003 Canadian dollars). Using probabilistic sensitivity analysis, 50% of all generated ICERs were lower than $57, and 95% were lower than $242 per additional day of ambulation. This analysis had a 95% CI of -$72.74 to 309.44, meaning that this intervention ranged from a financial savings of $72.74 to a cost of $309.44 per additional day of ambulation. Using survival as the measure of effectiveness resulted in an ICER of $30,940 per life-year gained.
We found strong evidence that treatment of metastatic epidural spinal cord compression with surgery in addition to radiotherapy is cost-effective both in terms of cost per additional day of ambulation, and cost per life-year gained.
Comment In: Int J Radiat Oncol Biol Phys. 2007 May 1;68(1):314; author reply 314-517448887
To evaluate the cost-effectiveness (CE) of new combined modality strategies in patients with stage III non-small-cell lung cancer (NSCLC).
Recent studies suggest that combined modality therapy confers a survival advantage for patients with stage III NSCLC. Using the Statistics Canada (Ottawa, Canada) lung cancer costing model, we have evaluated the CE of these interventions using 1993 Canadian health care costs and the perspective of the government as payer in a universal health care system.
We estimate that the cost to treat a stage IIIa NSCLC patient with preoperative and postoperative chemotherapy would increase by $15,886, and a similar combined modality approach with the addition of postoperative radiotherapy would increase the cost by $22,963. Chemoradiotherapy for stage IIIb NSCLC would produce a smaller incremental cost of approximately $8,912 per case. However, these approaches are remarkably cost-effective, with cost per life-year gained (LYG) ranging from $3,348 to $14,958. Administering all chemotherapy in the outpatient department would improve CE. For sensitivity analysis, we reduced the survival gain that resulted from the three interventions by 25% and 50%, and increased the hospital per diem rates by 10%, 20%, and 30%.
Even with the most adverse assumptions, the CE estimates were all considered acceptable for new health care technologies in Canada. Overall, it appears that neoadjuvant therapy for stage IIIa NSCLC and combined modality therapy for stage IIIb NSCLC are cost-effective. Economic considerations should not be a barrier to their adoption.
Against a background of constant or decreasing budgets, this study was undertaken to investigate the economic effects of changes in selected operational parameters within a radiation treatment programme. Using financial data from the Northeastern Ontario Regional Cancer Centre and a recognized staffing model, a commercial spreadsheet has been used to calculate the cost of an 18 fraction course of radiotherapy, including all the major preparatory processes such as simulation and treatment planning. Using the spreadsheet, and on the basis of explicit and reasonable assumptions, the cost of radiotherapy has been calculated as the facility size (i.e. equipment complement) and hours of operation are varied. Based on the assumptions used, the cost of radiotherapy in a facility treating less than about 1600 patients per year starts to rise. At 400 patients per year, a course costs approximately 50% more than at 1600 patients per annum. Extended hours of operation do not appear to generate significant, if any, savings when realistic assumptions about machine lifetime and overtime payments are made. Using a spreadsheet to simulate changes in a radiation treatment programme can be an important decision-making tool, as the effects of changes in operating parameters can be demonstrated.
This chapter addresses the economic aspects of radiotherapy. It includes a summary of the costs for radiotherapy in Sweden, a literature review of economic studies on cancer radiotherapy, and estimates of radiotherapy costs in Sweden for 1991. Appendix I describes the types of economic assessments relevant to an economic analysis of radiotherapy. Appendix II analyzes potential economies of scale, and the economic consequences of changed fractionation schedules. Cancer diagnosis and treatment accounts for approximately 5% of the total healthcare expenditure in Sweden (1), corresponding to 6.9 billion Swedish kronor (SEK) per year in 1993 monetary value. The costs of radiotherapy, an important modality for treating cancer, have not been fully described. This report presents such an estimate. The cost of external radiotherapy in Sweden in 1991 was approximately 260 million SEK. This corresponds to approximately 4% of the cost for cancer care. On average, the cost per irradiated field was approximately 500 SEK, the cost per fraction approximately 1125 SEK, and the cost per patient approximately 17,200 SEK. The estimates per patient vary widely by group. A rough estimate of the cost for curative radiotherapy for breast cancer would be approximately 31,000 SEK, which can be contrasted with a cost of approximately 7000 SEK for palliative treatment of bone metastases. The cost for brachytherapy in 1991 was, according to departmental financial reports, approximately 36 million SEK. Hence, the costs for external radiotherapy and brachytherapy were approximately 300 million SEK in 1991. In 1993 prices, this corresponds to approximately 330 million SEK, representing the total direct costs for radiotherapy in Sweden. However, this figure does not include costs for, eg, hospitalization in conjunction with radiotherapy, nor the other costs associated with this type of treatment. Several potential sources of error underlie these figures. The following overview presents and evaluates the foundation for these estimates. Appendix I to this chapter discusses the problem of how these estimates should be defined, and how costs should be related to the different ways for measuring treatment results.
An estimate of the average cost of treatment (COT) was assessed for 53 patients with pancreatic cancer treated between 1997 and 1999 in four hospitals in southern Sweden. Average COT was estimated to Euro18 947, 55% of which was attributable to hospitalization (including surgical procedures), 20% to long-term care and 11% to chemotherapy. Diagnostics and radiotherapy accounted for 9% and 4%, respectively. Median survival was 5.6 months (mean 6.3 months). Treatment costs per patient were negatively correlated with age but were higher for patients receiving chemo/radiotherapy and surgical treatment than for patients receiving only standard supportive care. Disease stage and type of hospital (university versus regional/local hospitals) were not significant predictors of COT per se. Assuming that our estimate of the average cost is representative for Sweden, the total healthcare cost for pancreatic cancer was Euro16 million (dollar14 million), i.e about 2-3% of the COT for all cancer diseases in Sweden. In the USA the cost of pancreatic cancer accounted for the same proportion. However, our estimated cost per patient was about half the amount of the US estimate. The distribution of costs between the different types of treatment services did not differ greatly between Sweden and the USA.