Use of Intensity-Modulated Radiotherapy Increasing and Costly in the Management of Head and Neck Cancers, but Value Unknown

September 2012, Vol 3, No 6 - Head and Neck Cancer


Toronto, Canada—The popularity of intensity-modulated radiotherapy (IMRT) for head and neck cancer has climbed rapidly in recent years. How­ever, the extra cost associated with this treatment modality may not equate with improved value, according to researchers from the University of California at Los Angeles (UCLA), who presented their analysis at the 2012 International Conference on Head and Neck Cancer.

The results showed that IMRT treatment was associated with ap­proximately 3-fold higher costs to Medicare than the costs of standard treatment. The team of researchers is calling for studies to investigate whether this increased cost correlates with significantly improved patient outcomes.

“Whereas IMRT has theoretical advantages, and there is some evidence for this, more prospective, randomized, and controlled studies are required to justify its wide use given the high cost,” lead investigator Ali Razfar, MD, Head and Neck Surgery resident at UCLA Medical Center, told Value-Based Cancer Care. “If there is no difference in overall quality of life and survival, then it may not justify the cost.”

A recent systematic review of 15 articles involving 1555 patients showed that IMRT is better than ex­ternal-beam radiotherapy (EBRT) at avoiding xerostomia, osteoradionecrosis, and blindness, but that there are insufficient data to show that IMRT provides better treatment-related outcomes (O’Sullivan B, et al. Clin Oncol. Epub 2012 June 18).

In this new analysis, Dr Razfar and colleagues reviewed data of 2817 patients who were diagnosed with a head and neck cancer between 2000 and 2007 and were included in the SEER (Surveillance, Epidemiology and End Results)-Medicare database. A total of 1359 patients were treated with traditional EBRT and 335 were treated with IMRT.

The 2 groups had similar demographics and disease stages. Patients undergoing EBRT were less likely to have oral-cavity cancer and more likely to have laryngeal cancer than their IMRT counterparts.

Between 2000 and 2007, the use of IMRT increased from 2% to 60%, whereas EBRT decreased from 98% to 40% (P <.001). No significant changes were observed over that time in the use of surgery alone, radiation alone, or surgery with adjuvant radiation, with the latter option dominating in each year.

The odds ratio (OR) of women receiving IMRT versus EBRT was 1.4; for patients who were also receiving chemotherapy, the OR was 3.3. In contrast, patients aged ≥80 years had an OR of 0.69 for receiving IMRT.

Cost Comparison
The mean total cost per case was $183,452 with IMRT compared with $63,618 for EBRT (P <.001). Oro­pharyn­geal cancer is one of the most costly head and neck cancers to treat. The average cost per oropharyngeal cancer was $200,907 with IMRT and $70,736 for EBRT (P <.001).

For treatment of early-stage tumors, surgery alone cost Medicare an average of $61,994 per case; in comparison, the average cost of EBRT was $66,123 per case compared with $183,294 with IMRT. This makes IMRT 2.9-fold more expensive than surgery and 2.7-fold more expensive than EBRT.

“We ended our analysis at 2007, because that was the last year of available data from the SEER-Medicare linked database,” noted Dr Razfar. “IMRT is even more widely used in 2012 than in 2007, and so the total cost to Medicare is likely much more than it was 5 years ago.”