Cost-Effective Strategy for Early NSCLC Hinges on Operability of the Disease

Charles Bankhead

November 2013, Vol 4, No 9 - Economics of Cancer Care

Atlanta, GA—Surgery and stereotactic body radiotherapy (SBRT) proved cost-effective strategies for stage I non–small-cell lung cancer (NSCLC) when applied to specific patient populations, according to a study reported at the 2013 American Society for Radiation Oncology meeting.

SBRT had the advantage for older patients with marginally operable disease, whereas lobectomy offered the most cost-effective option for patients with clearly operable disease.

“These findings were robust over a wide range of assumptions, including treatment efficacies, toxicities, costs, and health state utilities,” said Anand Shah, MD, MPH, Resident in the Department of Radiation Oncology, Columbia University Medical Center, New York.

Surgery has a long-standing history as the treatment for patients with clearly operable stage I NSCLC. For patients with marginally operable disease, wedge resection and SBRT have been employed with no clear evidence of superiority for one approach over the other.

Recent advances in the diagnosis of lung cancer will likely increase the population of patients with stage I disease, said Dr Shah. As a result, determining the cost-effectiveness of various treatment options is essential.

To address the cost-effectiveness issue, investigators used Markov modeling to compare treatment options for 2 hypothetical patient cohorts. For patients with marginally operable stage I NSCLC, they compared SBRT and wedge resection. For clearly operable disease, the comparison was SBRT versus lobectomy. SBRT efficacy was assumed to be the same in both comparisons, but the toxicity of SBRT was assumed to be greater in patients with marginally operable disease.

The investigators extracted disease, treatment, and toxicity data from the medical literature and these varied in sensitivity analyses. The investigators assumed a Medicare payer perspective and that all patients were treated at the same institution.

The surgical case mix was derived from 2011 data for the 18-county Philadelphia media market. The average surgery payment was a weighted average of payments for the case mix. The costs were adjusted to reflect 2012 US dollars, as determined from the Consumer Price Index. The costs and quality-adjusted life-years (QALYs) were discounted at 3% annually.

The analysis of the marginally operable cohort yielded a mean cost of $42,094 and a mean QALY of 8.03 for SBRT compared with $51,487 and 7.93, respectively, for wedge resection, demonstrating dominance for SBRT. For the clearly operable cohort, SBRT was associated with a mean cost of $40,107 and a mean QALY of 8.21, whereas lobectomy resulted in a mean cost of $49,093 and 8.89 QALYs.

The difference translated into an additional cost of $13,200 per QALY, which fell well within the definition of cost-effectiveness, and with additional QALYs, which rendered lobectomy the most cost-effective strategy for the clearly operable cohort.

“In the sensitivity analysis for the marginally operable cohort, SBRT was nearly always the dominant, and thus cost-effective, strategy,” said Dr Shah. “For the clearly operable cohort, lobectomy was the cost-effective treatment in every sensitivity analysis.”