The treatment of patients with brain metastases involves issues of controlling recurrence, side effects, and costs. A new analysis suggests that the novel approach of hippocampal-avoidance whole-brain radiotherapy (HA-WBRT) may be cost-effective for controlling brain metastases compared with other treatments (Savitz ST, et al. Cancer. 2015 Sep 15. Epub ahead of print).
The analysis involved a 5-year simulation of 100,000 patients aged ?65 years who had 1 to 3 brain metastases at baseline. For patients who survive a median of 1 year, whole-brain radiotherapy was cost-effective, at a cost of $42,872 per quality-adjusted life-year (QALY) gained. Findings showed that for patients who survive a median of 2 years, the combination of neurocognitive-sparing HA-WBRT with stereotactic radiosurgery (SRS) was the most cost-effective approach, with a cost of $80,253 per QALY gained.
Over the past few years, there has been a trend toward using radiosurgery alone for patients with more than 1 brain metastasis and reserving whole-brain radiotherapy as a salvage procedure only. This is because evidence from randomized trials and a meta-analysis have indicated that radiosurgery alone is associated with improved neurocognitive function and, perhaps, an increase in survival time.
However, the only prospective study published to date indicates that whole-brain radiotherapy successfully treats patients with brain metastases, with only moderate reduction in short-term memory.
In this new cost analysis, the investigators used a Markov model with a probabilistic sensitivity analysis that they ran for 60 one-month cycles: almost all patients with brain metastases die within 5 years.
For patients who survive a median of 3 months, none of the treatments analyzed were deemed cost-effective compared with HA-WBRT. For patients who survive a median of 6 months, radiosurgery with whole-brain radiotherapy salvage was cost-effective, with a $92,478 cost per QALY. At 12 months, HA-WBRT was associated with a $42,872 cost per QALY, which was reduced to $24,701 at 24 months. The cost per QALY was also below $100,000 at 24 months for radiosurgery plus HA-WBRT, at $80,253.
“The highest value treatment in patients with notably prolonged survival was SRS plus HA-WBRT, with the increased cost easily offset by improvements in disease control and the minimization of late brain toxicity,” the investigators noted. However, “1 significant cost consideration that is not incorporated into the analysis is the markedly increased time to plan and deliver HA-WBRT as well as the technical reality that it is largely limited to 1 radiotherapy system,” they added.
Senior investigator David J. Sher, MD, MPH, Associate Professor, Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, told Value-Based Cancer Care that the planning process for conventional whole-brain radiotherapy can take less than 30 minutes, whereas for HA-WBRT, it is typically several hours, and the treatment delivery is significantly longer and more involved.
“The ‘cost’ of more involved treatment planning and delivery is incorporated into the Medicare reimbursement for IMRT [intensity-modulated radiation therapy]-based planning, and thus implicitly included in the analysis,” said Dr Sher.
But “whether the additional planning and delivery costs associated with WBRT are reflected in the reimbursement for these treatments is an open question.”
Radiosurgery was cost-effective in patients with short (3-6 months) prognosis, whereas whole-brain radiotherapy and radiosurgery were both cost-effective in patients with longer (12-24 months) prognosis.
