ATLANTA – For older patients with marginally operable stage 1 non–small cell lung cancer, stereotactic body radiation therapy is significantly more cost effective than surgery.
For patients with clearly operable non–small cell lung cancer (NSCLS) tumors, however, lobectomy is the most cost-effective option, reported Dr. Anand Shah, a radiation oncology resident at Columbia University Medical Center in New York.
Neil Osterweil/IMNG Medical Media
Dr. Anand Shah
The findings, based on cost-effectiveness modeling, were robust over a wide range of assumptions, including various scenarios about treatment efficacies, toxicities, costs, and health state utilities.
"The rationale behind our study was that the traditional treatment for clearly operable patients with stage 1 lung cancer is lobectomy, whereas wedge resection and SBRT [stereotactic body radiation therapy] serve as alternatives in marginally operable patients. Given an aging population and an increased prevalence of screening, it is likely more people will be diagnosed with stage I lung cancer, and thus we felt it was critical to compare the cost effectiveness of these treatments," he said at the annual meeting of the American Society for Radiation Oncology.
The researchers created a Markov model in which hypothetical patient cohorts transition from one discrete, mutually-exclusive health state to another at fixed time increments and at defined probabilities.
For a cohort with marginally operable disease, they compared SBRT with wedge resection, and for a cohort with clearly operable disease, they compared SBRT with lobectomy. Patients in the model were older than age 65
The model assumes that in both cohorts, SBRT will be similarly efficacious, but with higher toxicity for marginally operable patients, who are more likely to experience treatment-related morbidities. The authors considered both open and less-invasive visually-assisted surgical procedures for patients undergoing lobectomy and wedge resection.
They considered costs from a Medicare perspective using 2012 dollars.
For the base case, SBRT for the marginally operable cohort cost a mean of $42,084, and the mean quality-adjusted life year (QALY) gain was 8.03 years. In contrast, wedge resection cost a mean of $51,487, for a QALY gain of 7.93 years. In statistical parlance, SBRT for this cohort was the less costly and most effective strategy.
For clearly operable patients, however, SBRT was less costly than surgery. The mean cost was $40,107 vs. $49,083, but with less efficacy at 8.21 QALY compared with 8.89 for lobectomy. The investigators calculated an incremental cost-effectiveness ratio favoring lobectomy in this cohort, at a cost of $13,200 per QALY gained.
Dr. James B. Yu
"We conducted a number of sensitivity analyses in which we varied the cost, efficacy, utility, and toxicity data, and in the marginally operable cohort SBRT was nearly always the dominant and thus cost-effective strategy. For patients who were considered clearly operable, lobectomy was the cost-effective treatment in nearly every sensitivity analysis," Dr. Shah said.
Dr. James B. Yu, the invited discussant, said that given current data, the findings of the study generally support current practice.
"However, even if you don’t agree that lobectomy is more cost effective for the clearly operable patient, at the very least this study will illuminate what we disagree about and where better data and clearer goals are needed," he said.
Dr. Yu is a therapeutic radiologist and cancer outcomes researcher at Yale School of Medicine in New Haven, Conn.
The funding source for the study was not disclosed. Dr. Shah and Dr. Yu reported having no relevant financial disclosures.