Cost-Effectiveness Analysis of Upfront SBRT for Oligometastatic Stage IV Non-Small Cell Lung Cancer Based on Mutational Status.

OBJECTIVES: Current National Comprehensive Cancer Network (NCCN) guidelines support systemic therapy based on mutational status in stage IV non-small cell lung cancer (NSCLC), with stereotactic body radiation therapy (SBRT) reserved for oligoprogression. We aimed to evaluate the cost-effectiveness of the routine addition of SBRT to upfront therapy in stage IV NSCLC by mutational subgroup. MATERIALS AND METHODS: A Markov state transition model was constructed to perform a cost-effectiveness analysis comparing SBRT plus maintenance therapy with maintenance therapy alone for oligometastatic NSCLC. Three hypothetical cohorts were analyzed: epidermal growth factor receptor or anaplastic lymphoma kinase mutation-positive, programmed death ligand-1 expressing, and mutation-negative group. Clinical parameters were obtained largely from clinical trial data, and cost data were based on 2018 Medicare reimbursement. Strategies were compared using the incremental cost-effectiveness ratio with effectiveness in quality-adjusted life years (QALYs) and evaluated with a willingness to pay threshold of $100,000 per QALY gained. RESULTS: SBRT plus maintenance therapy was not cost-effective at a $100,000/QALY gained threshold, assuming the same survival for both treatments, resulting in an incremental cost effectiveness ratio of $564,186 and $299,248 per QALY gained for the epidermal growth factor receptor or anaplastic lymphoma kinase positive and programmed death ligand-1 positive cohorts, respectively. Results were most sensitive to the cost of maintenance therapy. A large overall survival gain with SBRT could potentially result in upfront SBRT becoming cost-effective. For the mutation-negative cohort, upfront SBRT was nearly cost-effective, costing $128,424 per QALY gained. CONCLUSION: Adding SBRT to maintenance therapy is not a cost-effective strategy for oligometastatic NSCLC compared with maintenance therapy alone for mutation-positive groups. However, this should be validated via randomized trials.

Cost-effectiveness of sorafenib versus SBRT for unresectable advanced hepatocellular carcinoma.

OBJECTIVE: Stereotactic body radiotherapy (SBRT) has been shown to improve overall survival in patients with advanced hepatocellular carcinoma. This study aimed to assess the cost-effectiveness of SBRT compared to sorafenib which is the only drug for advanced hepatocellular carcinoma. METHODS: A Markov decision-analytic model was performed to compare the cost-effectiveness of SBRT and sorafenib for unresectable advanced hepatocellular carcinoma. Patients transitioned between three health states: stable disease, progression disease and death. We calculated the data on cost from the perspective of our National Health Insurance Bureau. Sensitivity analyses were conducted to determine the impact of several variables. RESULTS: The incremental cost effectiveness ratio (ICER) for sorafenib compared to SBRT was NT$3,788,238 per quality-adjusted life year gained (cost/QALY), which was higher than the willingness to pay threshold of Taiwan according to WHO's guideline. One-way sensitivity analysis revealed that the utility of progression disease for the sorafenib treatment, utility of progression free survival for SBRT, utility of progression free survival for sorafenib, utility of PFS to progression disease for SBRT and transition probability of progression disease to dead for SBRT were the most sensitive parameters in all cost scenarios. The Monte-Carlo simulation demonstrated that the probability of cost-effectiveness at a willingness to pay threshold of NT$ 2,213,145 per QALY was 100 % and 0 % chance for SBRT and sorafenib. CONCLUSION: This study indicated that SBRT for advanced hepatocellular carcinoma is cost-effective at a willingness to pay threshold as defined by WHO guideline in Taiwan.

Comparing the cost-effectiveness of two brain metastasis treatment modalities from a payer's perspective: stereotactic radiosurgery versus surgical resection.

OBJECTIVES: This study aims to identify the cost-effectiveness of two brain metastatic treatment modalities, stereotactic radiosurgery (SRS) versus surgical resection (SR), from the perspective of Germany's Statutory Health Insurance (SHI) System. METHODS: Retrospectively reviewing 373 patients with brain metastases (BMs) who underwent SR (n=113) and SRS (n=260). Propensity score matching was used to adjust for selection bias (n=98 each); means of survival time and survival curves were defined by the Kaplan-Meier estimator; and medical costs of follow-up treatment were calculated by the Direct (Lin) method. The bootstrap resampling technique was used to assess the impact of uncertainty. RESULTS: Survival time means of SR and SRS were 13.0, 18.4 months, respectively (P=0.000). Medians of free brain tumor time were 10.4 months for SR and 13.8 months for SRS (P=0.003). Number of repeated SRS treatments significantly influenced the survival time of SRS (R(2)=0.249; P=0.006). SRS had a lower average cost per patient (€9964 - SD: 1047; Skewness: 7273) than SR (€11647 - SD: 1594; Skewness: 0.465), leading to an incremental cost effectiveness ratio of €-3740 per life year saved (LYS), meaning that using SRS costs €1683 less than SR per targeted patient, but increases LYS by 0.45 years. CONCLUSION: SRS is more cost-effective than SR in the treatment of brain metastasis (BM) from the SHI perspective. When the clinical conditions allow it, early intervention with SRS in new BM cases and frequent SRS repetition in new BM recurrent cases should be advised.

Evaluación comparativa de efectividad y costo/efectividad en terapias alternativas para algunas lesiones vasculares encefálicas: experiencia del autor y revisión de la literatura / Comparative assessment of effectiveness and cost/effectiveness in alternative therapies to vascular encephalic lesions: author experience and review

Las patologías vasculares encefálicas quirúrgicas (aneurismas, malformaciones arterio venosas) han experimentado uno de los avances más importantes dentro de la medicina en las últimas décadas en materias de diagnóstico y tratamiento. Técnicas de introducción relativamente reciente y contemporánea, como la micro neurocirugía, la terapia endovascular encefálica y la radiocirugía, lograron mejorar en magnitudes las posibilidades de diagnóstico y los resultados de los tratamiento en estas lesiones. En este contexto parece de suma importancia definir el rol que juega cada uno de estos tratamientos en el manejo de la patología; así como la participación de los profesionales involucrados en la toma de decisiones muchas veces complejas y no exentas de controversia. El análisis de los resultados clínicos, la efectividad y la relación costo/efectividad son fundamentales para tener claridad en nuestro enfrentamiento como neurocirujanos tratantes. Este análisis debe interpretar la experiencia internacional en estas materias y a la vez revisar la experiencia local, hecho de suma importancia, que muchas veces dejamos rezagado en nuestro medio. Este estudio revisa los tópicos mencionados, incluyendo la experiencia del autor y un análisis exhaustivo de la bibliografía universal. Los resultados y las conclusiones podrán servir como herramienta a la hora de buscar referentes locales y foráneos que avalen con solidez nuestras conductas diagnósticas y terapéuticas.

Surgical vascular brain diseases (aneurysms, arterio venous malformations) have experienced one of the most important advances in medicine in the last decades related, to diagnosis and treatment. Recently and contemporary developed techniques, like micro neurosurgery, endovascular therapy and radiosurgery, have remarkably improved the diagnostic possibilities and the treatment outcomes in this lesions. In this context, it seems to be of the most importance to define the part that each treatment plays in the management of these diseases; and the participation of the professionals linked to the decision making in issues frequently complex and controversial. The analysis of clinical outcomes, the effectiveness and the cost/effectiveness ratio are basic to be clear in our approaches like neurosurgeons. This article reviews the international literature in these topics and, at the same time, the local experience, a fact of enormous importance that we use to left behind. The previously mentioned issues are reviewed, including the author's own experience and an exhaustive bibliographic analysis. Some of the results and conclusions included article should be useful tools when searching for local and foreign references to endorse with strength our diagnostic and therapeutic behaviour.