Xie et al 2020
Cost Eff Resour Alloc · 2020 · United States · Proton
This Markov cohort cost-utility study from the United States, taking a payer perspective over 15 years, compared standard of care and several advanced post-mastectomy radiotherapy techniques for Stage III breast cancer. The model simulated a cohort of 55-year-old postmenopausal women receiving 50 Gy in 25 fractions, with transition probabilities, utilities and costs taken from the literature and Medicare data; no real patients were studied. Standard volumetric modulated arc therapy was reported at US$32,617 per QALY relative to standard of care, IMRT at US$19,081 per QALY relative to standard volumetric modulated arc therapy, and intensity-modulated proton therapy at US$151,741 per QALY relative to IMRT. The authors concluded that advanced techniques are more cost-effective at a willingness-to-pay threshold of US$100,000 per QALY, and that IMRT might be a cost-effective option.
What it compared
Intensity-modulated proton therapy (IMPT) against IMRT, and other advanced post-mastectomy techniques (STD-VMAT, NC-VMAT, MA-VMAT, Tomotherapy, mixed beam) against standard of care, in a simulated cohort of 55-year-old women with Stage III breast cancer.
What it found
The incremental cost-effectiveness ratio for IMPT relative to IMRT was US$151,741 per QALY, and for STD-VMAT relative to standard of care was US$32,617 per QALY; the study's willingness-to-pay thresholds were US$50,000 per QALY and US$100,000 per QALY.
What to keep in mind
The costs are reported with the price year not stated, the discount rate is not stated, and the cohort is simulated from published parameters rather than real patients, so the figures depend heavily on model assumptions, with cardiac toxicity probability the most influential single parameter in one-way analysis.
The figures it reported
- US$ 32,617 per QALYVMAT vs SOC
- US$ 19,081 per QALYIMRT (vs STD-VMAT per abstract)
- US$ 151,741 per QALYIMPT (vs IMRT per abstract)
Figures are shown exactly as the paper gives them, in its own currency and price year. We do not convert between currencies: see the glossary for why.
- Patients modelled or enrolled
- Simulated cohort of 55-year-old postmenopausal women with Stage III breast cancer, 50 Gy in 25 fractions post-mastectomy; no real patients, parameters from published literature
- Comparator
- Standard of care (SOC); also IMRT, VMAT, Tomotherapy, mixed beam
- Indication
- Breast cancer (post-mastectomy, Stage III)
- Study design
- Cost-utility analysis, Markov cohort model
- Time horizon
- 15 years
- Delivery technique
- IMPT
- Perspective
- Payer perspective
- Currency
- US$
- Price year
- not reported by this study
- Willingness-to-pay threshold
- US$50,000/QALY (also US$100,000/QALY considered)
- Discount rate
- not reported by this study
- Cost of the particle course assumed
- US$ 33,547 (IMPT)
- Cost of the comparator assumed
- SOC: US$ 12,140; VMAT/TOMO/IMRT: US$ 17,438; Mixed: US$ 19,715
Whose costs were counted: a payer, a hospital, or society as a whole.
The year the costs are expressed in. Without it, a figure cannot be compared across time.
The condition attached to the finding
IMPT is not cost-effective vs SOC at a WTP of US$50,000/QALY; at a WTP of US$100,000/QALY IMPT is more cost-effective than SOC 99.9% of the time (probabilistic sensitivity analysis).
Reporting quality
77 out of 100 on the Quality of Health Economic Studies instrument, a 16-item checklist covering the objective, the perspective, the sources of each estimate, the handling of uncertainty, the horizon and discounting, how costs were measured, the model's transparency, the discussion of bias, and whether funding was disclosed. It measures how well the study was reported, not whether its conclusion is correct: a well-reported study can still reach a conclusion a later trial overturns.