Long-Term Cost-Effectiveness Comparison of Catheter Ablation and Antiarrhythmic Drugs in Atrial Fibrillation Treatment Using Discrete Event Simulation.

OBJECTIVES: To evaluate the lifetime cost-effectiveness of 3 widely used atrial fibrillation (AF) treatments from the perspectives of Chinese healthcare system: antiarrhythmic drugs (AADs), ThermoCool SmartTouch guided by ablation index (STAI), and second-generation cryoballoon (CB2). METHODS: A discrete event simulation (DES) model was implemented to compare the lifetime cost-effectiveness of AADs, STAI, and CB2. AF disease progression was explicitly modeled based on the Atrial Fibrillation Progression Trial clinical study results. The base-case analysis assumed that patients with paroxysmal AF (PAF) entered the model at the age of 55 years and had a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ( > 65 = 1 point, > 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points)-Vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), Age 65 to 74 years, and Sex category) score of 2 for males and 3 for females. Model parameter uncertainties were incorporated throughout the DES simulation with full probabilistic model parameterization. RESULTS: The lifetime cost-effectiveness evaluations showed that patients treated with AADs gained an average of 4.98 quality-adjusted life-years (QALYs) and 9.63 life-years (LYs) at an average cost of US dollar (USD) 15 374. Patients treated with CB2 gained 5.92 QALYs and 10.74 LYs at an average cost of USD 26 811. The STAI group gained an average of 6.55 QALYs and 11.57 LYs at an average cost of USD 24 722. The incremental cost-effectiveness ratios was USD 5927 and USD 12 167 per QALY for STAI versus AADs and CB2 versus AADs, respectively. Assuming the willingness-to-pay threshold for China is USD 30 390 per QALY, both ablation treatments will be cost-effective compared with AADs for patients with PAF. CONCLUSIONS: The DES model demonstrated that catheter ablations are more cost-effective than AADs for patients with PAF under the healthcare system in China. Among catheter ablation technologies, STAI provides better outcomes at lower costs.

Efficacy and safety of single- and multiple-antenna microwave ablation for the treatment of hepatocellular carcinoma and liver metastases: A systematic review and network meta-analysis.

BACKGROUND: There is a myriad of microwave ablation (MWA) systems used in clinical settings worldwide for the management of liver cancer that offer a variety of features and capabilities. However, an analysis on which features and capabilities result in the most favorable efficacy and safety results has never been completed due to a lack of head-to-head comparisons. The aim of this study is to compare single-antenna and multiple-antenna MWA using radiofrequency ablation (RFA) as a common comparator in the treatment of very-early, early hepatocellular carcinoma (HCC) and ≤5 cm liver metastases. METHODS: This network meta-analysis was performed according to PRISMA guidelines. PubMed, Cochrane, and Web of Science databases were searched for comparative studies. Complete ablation (CA) rate, local tumor progression-free (LTPF) rate, overall survival (OS), and major complication rate were assessed. Subgroup analyses were further performed based on synchronous or asynchronous MWA generators and tumor size (<2 cm or ≥2 cm). RESULTS: Twenty-one studies (3424 patients), including 3 randomized controlled trials (RCTs) and 18 observational studies, met eligibility criteria. For CA, LTPF and major complications, as compared to single-antenna MWA, multiple-antenna MWA had relative risks (RRs) of 1.051 (95% CI: 0.987-1.138), 1.099 (95% CI: 0.991-1.246), and 0.605 (95% CI: 0.193-1.628), respectively. For 1-year and 3-year OS, as compared to single-antenna MWA, multiple-antenna MWA had odds ratios (ORs) of 0.9803 (95% CI: 0.6772-1.449) and 1.046 (95% CI: 0.615-1.851), respectively. Subgroup analysis found synchronized multi-antenna MWA was associated with significantly better LTPF by 22% (RR: 1.22, 95% CI 1.068, 1.421), and 21.4% (RR: 1.214, 95% CI 1.035, 1.449) compared with single-antenna MWA, and asynchronous multiple-antenna MWA, respectively, with more evident differences in larger tumors (≥2 cm). CONCLUSION: Multi-antenna and single-antenna MWA showed similar effectiveness for local treatment of liver tumors, but synchronous multi-antenna MWA exhibited better LTPF compared to other MWA approaches, particularly for larger liver tumors (≥2 cm). Large-scale RCTs should be further conducted.

Magnetic resonance imaging-based treatment planning for prostate cancer: Use of population average tissue densities within the irradiated volume to improve plan accuracy.

PURPOSE: The purpose of this study was to investigate the feasibility of using population average tissue densities within the irradiated volume to improve the dosimetric accuracy of magnetic resonance imaging-based treatment plans for prostate cancer. METHODS AND MATERIALS: Computed tomography images and radiation therapy treatment plans from 20 patients with prostate cancer were reviewed retrospectively. Patient anatomy was segmented into fat, nonfat soft tissue, and bone. Population average tissue densities within the irradiated volume were obtained. Two bulk density override plans were generated using the tissue densities reported in International Commission on Radiation Units & Measurements Report 46 and those obtained in this study, respectively. Both plans were compared to the clinically approved computed tomography-based plan to assess dosimetric accuracy. RESULTS: The population average tissue densities within the irradiated volume obtained in this study were found to be different from those reported in International Commission on Radiation Units & Measurements Report 46. Use of the population average tissue densities within the irradiated volume reduced dosimetric errors for all dose metrics, for example, V100 (percentage of prostate volume receiving 100% of the prescription dose; 0.32% vs 1.73%), D95 (dose covering 95% of the target volume; 0.32% vs 0.92%), D50 (dose covering 50% of the target volume; 0.30% vs 0.89%), and maximum dose to bladder (0.37% vs 0.78%), rectum (0.35% vs 0.95%), and penile bulb (0.23% vs 0.49%). All improvements were statistically significant. CONCLUSIONS: Use of population average tissue densities within the irradiated volume by the density override technique can improve the dosimetric accuracy of magnetic resonance imaging-based treatment plans for prostate cancer.