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Title: Economic consequence of local control with radiotherapy: Cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer

Abstract

Purpose: To investigate the financial implications of radiotherapy (RT) to the internal mammary and medial supraclavicular lymph node chain (IM-MS) in postoperative breast cancer. Methods and Materials: A cost-effectiveness and cost-utility analysis were performed, using Markov models, comparing the early and delayed costs and effects of IM-MS during a 20-year time span from a societal viewpoint. The outcome estimates were based on Level I evidence from postoperative RT literature and the cost estimates on the standard practice of the Leuven University Hospitals, with the RT costs derived from an activity-based costing program developed in the department. Results: On the basis of the assumptions of the model and seen during a 20-year time span, primary treatment including IM-MS RT results in a cost savings (approximately EURO 10,000) compared with a strategy without RT. Because IM-MS RT also results in better clinical effectiveness and greater quality of life, the treatment with IM-MS dominates the approach without IM-MS. Sensitivity analyses confirmed the robustness of these results in all tested circumstances. Although threshold values were found for the cost of IM-MS, the cost at relapse, and the quality of life after treatment, these were substantially different from the baseline estimates, indicating that it ismore » very unlikely that omitting IM-MS would become superior. Conclusion: This ex-ante cost evaluation of IM-MS RT showed that the upfront costs of locoregional RT are easily compensated for by avoiding the costs of treating locoregional and distant relapse at a later stage. The cost-sparing effect of RT should, however, be evaluated for a sufficiently long time span and is most specifically found in tumors with a rather slow natural history and a multitude of available systemic treatments at relapse, such as breast cancer.« less

Authors:
 [1];  [2];  [3]
  1. Department of Radiation Oncology, University Hospitals Leuven, Leuven (Belgium). E-mail: yolande.lievens@uz.kuleuven.ac.be
  2. University Hospitals Leuven and Center for Health Services and Nursing Research, KU Leuven, Leuven (Belgium)
  3. Department of Radiation Oncology, University Hospitals Leuven, Leuven (Belgium)
Publication Date:
OSTI Identifier:
20706257
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 63; Journal Issue: 4; Other Information: DOI: 10.1016/j.ijrobp.2005.03.064; PII: S0360-3016(05)00604-8; Copyright (c) 2005 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; CARCINOMAS; COST; EVALUATION; HOSPITALS; LYMPH NODES; MAMMARY GLANDS; MARKOV PROCESS; RADIOTHERAPY; SENSITIVITY ANALYSIS

Citation Formats

Lievens, Yolande, Kesteloot, Katrien, and Bogaert, Walter van den. Economic consequence of local control with radiotherapy: Cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer. United States: N. p., 2005. Web. doi:10.1016/j.ijrobp.2005.03.064.
Lievens, Yolande, Kesteloot, Katrien, & Bogaert, Walter van den. Economic consequence of local control with radiotherapy: Cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer. United States. doi:10.1016/j.ijrobp.2005.03.064.
Lievens, Yolande, Kesteloot, Katrien, and Bogaert, Walter van den. Tue . "Economic consequence of local control with radiotherapy: Cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer". United States. doi:10.1016/j.ijrobp.2005.03.064.
@article{osti_20706257,
title = {Economic consequence of local control with radiotherapy: Cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer},
author = {Lievens, Yolande and Kesteloot, Katrien and Bogaert, Walter van den},
abstractNote = {Purpose: To investigate the financial implications of radiotherapy (RT) to the internal mammary and medial supraclavicular lymph node chain (IM-MS) in postoperative breast cancer. Methods and Materials: A cost-effectiveness and cost-utility analysis were performed, using Markov models, comparing the early and delayed costs and effects of IM-MS during a 20-year time span from a societal viewpoint. The outcome estimates were based on Level I evidence from postoperative RT literature and the cost estimates on the standard practice of the Leuven University Hospitals, with the RT costs derived from an activity-based costing program developed in the department. Results: On the basis of the assumptions of the model and seen during a 20-year time span, primary treatment including IM-MS RT results in a cost savings (approximately EURO 10,000) compared with a strategy without RT. Because IM-MS RT also results in better clinical effectiveness and greater quality of life, the treatment with IM-MS dominates the approach without IM-MS. Sensitivity analyses confirmed the robustness of these results in all tested circumstances. Although threshold values were found for the cost of IM-MS, the cost at relapse, and the quality of life after treatment, these were substantially different from the baseline estimates, indicating that it is very unlikely that omitting IM-MS would become superior. Conclusion: This ex-ante cost evaluation of IM-MS RT showed that the upfront costs of locoregional RT are easily compensated for by avoiding the costs of treating locoregional and distant relapse at a later stage. The cost-sparing effect of RT should, however, be evaluated for a sufficiently long time span and is most specifically found in tumors with a rather slow natural history and a multitude of available systemic treatments at relapse, such as breast cancer.},
doi = {10.1016/j.ijrobp.2005.03.064},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 4,
volume = 63,
place = {United States},
year = {Tue Nov 15 00:00:00 EST 2005},
month = {Tue Nov 15 00:00:00 EST 2005}
}
  • We assessed the impact of internal mammary chain radiotherapy (IMC RT) to the radiation dose received by the heart in terms of heart dose-volume histogram (DVH). Thirty-six consecutive breast cancer patients presenting with indications for IMC RT were enrolled in a prospective study. The IMC was treated by a standard conformal RT technique (50 Gy). For each patient, a cardiac DVH was generated by taking into account the sole contribution of IMC RT. Cardiac HDV were compared according to breast cancer laterality and the type of previous surgical procedure, simple mastectomy or breast conservative therapy (BCT). The contribution of IMCmore » RT to the heart dose was significantly greater for patients with left-sided versus right-sided tumors (13.8% and 12.8% for left-sided tumors versus 3.9% and 4.2% for right-sided tumors in the BCT group and the mastectomy group, respectively; p < 0.0001). There was no statistically significant difference in IMC contribution depending on the initial surgical procedure. IMC RT contributes to cardiac dose for both left-sided and right-sided breast cancers, although the relative contribution is greater in patients with left-sided tumors.« less
  • Purpose: The Korean Radiation Oncology Group (KROG) 08-06 study protocol allowed radiation therapy (RT) technique to include or exclude breast cancer patients from receiving radiation therapy to the internal mammary lymph node (IMN). The purpose of this study was to assess dosimetric differences between the 2 groups and potential influence on clinical outcome by a dummy run procedure. Methods and Materials: All participating institutions were asked to produce RT plans without irradiation (Arm 1) and with irradiation to the IMN (Arm 2) for 1 breast-conservation treatment case (breast-conserving surgery [BCS]) and 1 mastectomy case (modified radical mastectomy [MRM]) whose computed tomographymore » images were provided. We assessed interinstitutional variations in IMN delineation and evaluated the dose-volume histograms of the IMN and normal organs. A reference IMN was delineated by an expert panel group based on the study guidelines. Also, we analyzed the potential influence of actual dose variation observed in this study on patient survival. Results: Although physicians intended to exclude the IMN within the RT field, the data showed almost 59.0% of the prescribed dose was delivered to the IMN in Arm 1. However, the mean doses covering the IMN in Arm 1 and Arm 2 were significantly different for both cases (P<.001). Due to the probability of overdose in Arm 1, the estimated gain in 7-year disease-free survival rate would be reduced from 10% to 7.9% for BCS cases and 7.1% for MRM cases. The radiation doses to the ipsilateral lung, heart, and coronary artery were lower in Arm 1 than in Arm 2. Conclusions: Although this dummy run study indicated that a substantial dose was delivered to the IMN, even in the nonirradiation group, the dose differences between the 2 groups were statistically significant. However, this dosimetric profile should be studied further with actual patient samples and be taken into consideration when analyzing clinical outcomes according to IMN irradiation.« less
  • Purpose: To estimate errors in soft tissue-based image guidance due to relative changes between primary tumor (PT) and affected lymph node (LN) position and volume, and to compare the results with bony anatomy-based displacements of PTs and LNs during radiotherapy of lung cancer. Methods and Materials: Weekly repeated breath-hold computed tomography scans were acquired in 17 lung cancer patients undergoing radiotherapy. PTs and affected LNs were manually contoured on all scans after rigid registration. Interfraction and intrafraction displacements in the centers of mass of PTs and LNs relative to bone, as well as LNs relative to PTs (LN-PT), were calculated.more » Results: The mean volume after 5 weeks was 65% for PTs and 63% for LNs. Systematic and random interfraction displacements were 2.6 to 4.6 mm and 2.7 to 2.9 mm, respectively, for PTs; 2.4 to 3.8 mm and 1.4 to 2.7 mm, respectively, for LNs; and 2.3 to 3.9 mm and 1.9 to 2.8 mm, respectively, for LN-PT. Systematic and random intrafraction displacements were less than 1 mm except in the superoinferior direction. Interfraction LN-PT displacements greater than 3 mm were observed in 67% of fractions and require a safety margin of 12 mm in the lateral direction, 11 mm in the anteroposterior direction, and 9 mm in the superoinferior direction. LN-PT displacements displayed significant time trends (p < 0.0001) and depended on the presence of pathoanatomic conditions of the ipsilateral lung, such as atelectasis. Conclusion: Interfraction LN-PT displacements were mostly systematic and comparable to bony anatomy-based displacements of PTs or LNs alone. Time trends, large volume changes, and the influence of pathoanatomic conditions underline the importance of soft tissue-based image guidance and the potential of plan adaptation.« less
  • Purpose: To assess whether using an anterior oblique supraclavicular (SCV) field with a posterior axillary boost (PAB) field is an optimal technique for targeting axillary (AX) lymph nodes compared with two computed tomography (CT)-based techniques: (1) an SCV field with an anterior boost field and (2) intensity-modulated radiotherapy (IMRT). Methods and Materials: Ten patients with CT simulation data treated with postmastectomy radiation that included an SCV field were selected for the study. Supraclavicular nodes and AX Level I-III nodes within the SCV field were contoured and defined as the treatment target. Plans using the three techniques were generated and evaluatedmore » for each patient. Results: The anterior axillary boost field and IMRT resulted in superior dose coverage compared with PAB. Namely, treatment volumes that received 105%, 80%, and 30% of prescribed dose for IMRT plans were significantly less than those for the anterior axillary boost plans, which were significantly less than PAB. For PAB and anterior axillary boost plans, there was a linear correlation between treatment volume receiving 105% of prescribed dose and maximum target depth. Furthermore, the IMRT technique resulted in better lung sparing and dose conformity to the target than anterior axillary boost, which again was significantly better than PAB. The maximum cord dose for IMRT was small, but higher than for the other two techniques. More monitor units were required to deliver the IMRT plan than the PAB plan, which was more than the anterior axillary boost plan. Conclusions: The PAB technique is not optimal for treatment of AX lymph nodes in an SCV field. We conclude that CT treatment planning with dose optimization around delineated target volumes should become standard for radiation treatments of supraclavicular and AX lymph nodes.« less
  • The effect of internal mammary chain treatment on each type of malignant death-related event was analyzed in 1195 patients with operable breast cancer and histologically involved axillary lymph nodes. A group of 135 patients who had no internal mammary chain treatment was compared with a control group of 1060 patients who were treated by surgery and/or postoperative radiation therapy. In a multivariate analysis taking into account age, clinical size of the tumor, histoprognostic grading, and the number of positive axillary lymph nodes, quantitative interaction tests were used to determine whether the effects of internal mammary chain treatment on each typemore » of malignant event were significantly different for patients with a lateral tumor compared with those with a medial tumor. The authors found that the effects of this treatment on the risks of distant metastases and of secondary breast cancer were not the same for the patients with a medial tumor as for those with a lateral tumor. For the untreated patients with a medial tumor, the risks of distant metastases and second breast cancer were, respectively, 1.6 (P = 0.02) and 2.9 (P = 0.02), compared with the treated patients. Conversely, for women with lateral tumor, no difference between the two treatment groups was observed. Thus, internal mammary chain treatment may improve long-term survival rate in patients with a medial tumor and positive axillary lymph nodes essentially by decreasing the risk of development of distant metastases (mainly brain, distant lymph nodes, multiple simultaneous metastases) and/or a secondary breast cancer.« less