Neha P. Amin

Systematic review of the cost effectiveness of radiation therapy for prostate cancer from 2003 to 2013.

BackgroundProstate cancer remains a prevalent diagnosis with a spectrum of treatment choices that offer similar oncologic outcomes but differing side effect profiles and associated costs. As the technology for prostate radiation therapy has advanced, its associated costs have escalated, thus making cost-effectiveness analyses critical to assess the value of competing treatment options, including watchful waiting, surgery, brachytherapy, intensity-modulated radiation therapy (IMRT), 3D-conformal radiation therapy (3D-CRT), proton beam therapy (PBT), and stereotactic body radiation therapy (SBRT).ObjectiveThe aim of this systematic review was to identify articles that performed a cost-effectiveness analysis on different radiation treatment options for localized prostate cancer, summarize their findings, and highlight the main drivers of cost effectiveness.MethodsA literature search was performed on two databases, PubMed and the Cost-Effectiveness Analysis Registry (https://research.tufts-nemc.org/cear4), using search terms that included ‘prostate’, ‘cost effectiveness prostate radiation’ and ‘cost analysis comparative effectiveness prostate radiation’. Studies were included in this review if the cost data were from 2002 or later, and outcomes reported both cost and effectiveness, preferably including a cost–utility analysis with the outcome of an incremental cost-effectiveness ratio with quality-adjusted life-year (QALY) as the effectiveness measure.ResultsThere were 14 articles between 2003 and 2013 that discussed cost effectiveness of prostate radiotherapy in men over the age of 65. All but four of the papers were from the US; the others were from Canada and the UK. The majority of the papers used Markov decision analysis and estimated cost from a payer’s perspective, usually from Medicare reimbursement data. Assumptions for the model and utilities to calculate QALYs were estimated using published literature at the time of the analysis. Each analysis had a sensitivity analysis to compensate for the uncertainty of the model inputs. The main drivers of cost effectiveness were the cost of the radiation treatment and the differential QALYs accrued because of different treatment-related morbidities. Brachytherapy was consistently found to be more cost effective when compared with surgery and other radiation treatment options. IMRT was cost effective when compared with 3D-CRT. PBT was not found to be cost effective in any of the analyses, mostly due to the high costs of PBT. SBRT was the newest technology that was analyzed, and it was also found to be cost effective compared with IMRT and PBT.ConclusionsCost-effectiveness research of prostate radiation treatments allows patients, providers, and payers to better understand the true value of each treatment choice. Due to the variation in each of these analyses (e.g., costing, and disease and complication assumptions, etc.), it is difficult to generalize the results. One must be careful in drawing conclusions from these studies and extrapolating to individual patients, particularly with the clear utility dependence seen in the majority of these studies.

Intensity-modulated radiation therapy for prostate cancer is cost effective and improves therapeutic ratio

Radiation therapy is one of the standard treatment options for many prostate cancer patients. Intensity-modulated radiation therapy (IMRT) allows for more conformal dose distributions that can reduce normal tissue toxicity compared with older external beam techniques. There has been a rapid adoption of IMRT between 2001 and 2007 for prostate cancer patients regardless of the patients’ race, socioeconomic status or disease risk classification. IMRT is more expensive than older radiation techniques and has an impact on healthcare spending for prostate cancer.

Effect of induction chemotherapy on estimated risk of radiation pneumonitis in bulky non–small cell lung cancer

Patients with bulky non-small cell lung cancer (NSCLC) may be at a high risk for radiation pneumonitis (RP) if treated with up-front concurrent chemoradiation. There is limited information about the effect of induction chemotherapy on the volume of normal lung subsequently irradiated. This study aims to estimate the reduction in risk of RP in patients with NSCLC after receiving induction chemotherapy. Between 2004 and 2009, 25 patients with Stage IV NSCLC were treated with chemotherapy alone (no surgery or radiation therapy [RT]) and had computed tomography (CT) scans before and after 2 cycles of chemotherapy. Simulated RT plans were created for the prechemotherapy and postchemotherapy scans so as to deliver 60Gy to the thoracic disease in patients who had either a >20% volumetric increase or decrease in gross tumor volume (GTV) from chemotherapy. The prechemotherapy and postchemotherapy scans were analyzed to compare the percentage of lung volume receiving≥20Gy (V20), mean lung dose (MLD), and normal tissue complication probability (NTCP). Eight patients (32%) had a GTV reduction >20%, 2 (8%) had GTV increase >20%, and 15 (60%) had stable GTV. In the 8 responders, there was an absolute median GTV decrease of 88.1cc (7.3 to 351.6cc) or a 48% (20% to 62%) relative reduction in tumor burden. One had >20% tumor progression during chemotherapy, yet had an improvement in dosimetric parameters postchemotherapy. Among these 9 patients, the median decrease in V20, MLD, and NTCP was 2.6% (p<0.01), 2.1Gy (p<0.01), and 5.6% (p<0.01), respectively. Less than one-third of patients with NSCLC obtain >20% volumetric tumor reduction from chemotherapy alone. Even with that amount of volumetric reduction, the 5% reduced risk of RP was only modest and did not convert previously ineligible patients to safely receive definitive thoracic RT.

Helical Therapy is Safe for Lung Stereotactic Body Radiation Therapy Despite Limitations in Achieving Sharp Dose Gradients

Purpose: We observed that many of our helical therapy lung stereotactic body radiation therapy plans did not meet the Radiation Therapy Oncology Group (RTOG) recommended R50% (volume of 50% of the prescription dose/planning target volume), which characterizes the steepness of dose fall off. We hypothesized that despite not meeting R50%, helical therapy lung stereotactic body radiation therapy plans would confer similar local control and minimal side effects as previously reported using nonhelical treatment platforms. Materials and Methods: We report a retrospective review of all consecutive patients treated off-protocol with stereotactic body radiation therapy for peripheral lung lesions from 2008 to 2013 utilizing helical therapy. Seventy-four patients (81 lesions and 79 plans) were treated with doses ranging from 48 to 60 Gy in 3 to 5 fractions prescribed to the edge of the planning target volume. Results: Forty-eight (61%) plans had major deviation from R50%. Only 1 (<1%) plan had a major deviation from the R100%. All plans had > 95% planning target volume coverage by prescription dose, 7(8.6%) plans with 121% to 133% maximum dose, and lung V20 Gy <10% in 70 (89%) plans. With a median follow-up of 4.7 years (95% confidence interval: 4.1-5.3), local control for all patients at 1, 2, and 5 years was 94.6%, 83.4%, and 74%, respectively. For patients with primary stage I-II lung cancer (n = 46), the 1, 2, and 5-year local control: 97.2%, 94.2%, and 86.9%; RC: 97.6%, 82.5%, and 69.5%; and DM: 3%, 16%, and 33.4%, respectively. Patients treated for lung metastases (n = 26) had worse local control at 1, 2, and 5 years: 94.4%, 69.3%, and 55.5%, respectively. Side effects were rare with 2 (3%) patients reporting chest wall pain and 6 (8%) patients experiencing radiation pneumonitis, including 1 patient who had grade 5 radiation pneumonitis. Conclusions: Helical therapy delivers a safe and effective lung stereotactic body radiation therapy plan, despite not being able to meet RTOG’s recommended R50 conformality constraint.

Abstract P1-15-24: Skin toxicities of obese African American breast cancer patients treated with hypofractionated radiation therapy

Objective: Hypofractionated radiation therapy (HFRT) for early stage breast cancer is an established treatment option with equivalent cancer outcomes and better cosmetic results than standard fractionation. There is limited published information about expected skin changes of African-American breast cancer patients (pts) undergoing HFRT. While HFRT is not recommended for women with large breasts, the use of prone position may allow for homogeneous HFRT plans. We prospectively monitored and reported on skin changes in African-American pts who received HFRT for their breast cancer. Methods: A retrospective analysis at a single institution from 12/2012 to 08/2013 was performed to identify early stage breast cancer pts who underwent breast conservation surgery and received adjuvant whole-breast HFRT. An assessment form had been created to prospectively document weekly changes in radiation dermatitis (CTCAE V.4 Grade 0-4) and hyperpigmentation (none, faint, moderate, severe). Photographs of the treated area were collected before and at the end of treatment. Treatment planning guidelines were per RTOG 1005. Results: There were 15 African-American pts with Tis-T2N0M0 breast cancer who were treated with HFRT to a dose of 4256 cGy in 16 fractions (266 cGy per fraction) followed by a lumpectomy cavity boost of 1000-1250 cGy (250cGy per fraction). There were 12 (80%) pts with right-breast cancer and 6 (40%) who were treated in the prone position. The median age was 61 (36-70). The median body mass index (BMI) for the pts treated in the prone position (42.2 [36-54]) was greater than the median BMI for pts treated in the supine position (29.7 [26-43]). The median breast volume of the prone pts (2335cc [2163-3369]) was more than twice the median volume of supine pts (920cc [231-1459]). The median separation distance for prone and supine pts were 25.1cm (17.5-31.2) and 22.5cm (17.5- 31.8), respectively. Radiation dermatitis: None (6%), Grade 1 (60%), Grade 2 (34%), Grade 3 (none). Only three pts had desquamation:1 pt had dry, and two pts had both dry and minimal moist desquamation in the infra-mammary fold. Hyperpigmentation: none (6.5%), faint (40%), moderate (47%), severe (6.5%). The areas of severe hyperpigmentation correlated to areas of desquamation. The median DMax, mean heart dose, and ipsilateral lung V20Gy were 107.2% (105.2 – 109.9), 60 cGy (29 – 544), and 8.25% (0.0 – 23), respectively. Conclusion: African-American pts treated with HFRT experience minor skin toxicities with mostly Grade 1 dermatitis and moderate hyperpigmentation changes. Obese African-American pts can safely be treated with HFRT if they can be placed in the prone position. Some pts with a separation of > 25cm can be safely and effectively treated with HFRT. Citation Format: Arun G Paul, Amy Collins, Gregory Dyson, Neha Amin. Skin toxicities of obese African American breast cancer patients treated with hypofractionated radiation therapy [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-15-24.