Li et al 2021
BMC cancer · 2021 · China · Proton
This cost-utility study modelled intensity-modulated proton radiation therapy (IMPT) against conventional intensity-modulated photon radiation therapy (IMRT) for oropharyngeal cancer in China, using a 7-state Markov model with a lifetime horizon. The base case was a hypothetical 56-year-old patient, with the assumption that IMPT reduces normal tissue complication probability by 25% for long-term symptomatic dysphagia and xerostomia. The authors concluded that cost-effective scenarios for IMPT exist at the current Chinese willingness-to-pay threshold, but only under specified conditions.
What it compared
IMPT versus IMRT, with IMRT costed at $12,000 per course, for a hypothetical cohort of oropharyngeal cancer patients in China, with age subgroups of 10 to 50 years also modelled.
What it found
In the base case, IMPT gave an extra 0.205 QALY at an additional cost of US$34,926.6, an ICER of US$170,082.4 per QALY, which is well above the current Chinese willingness-to-pay threshold of US$33,558 per QALY.
What to keep in mind
The result depends heavily on the assumed 25% NTCP reduction, which is a modelled assumption rather than a measured outcome, and the price year for costs is not stated, so the figures may not reflect current prices.
The figures it reported
- US$170,082.4 per QALYIMPT vs IMRT, base case (56-year-old)
Figures are shown exactly as the paper gives them, in its own currency and price year. We do not convert between currencies: see the glossary for why.
- Patients modelled or enrolled
- Hypothetical base case of a 56-year-old patient with oropharyngeal cancer (median age of OPC in China); age subgroups 10, 20, 30, 40 and 50 years also modelled
- Comparator
- intensity-modulated photon-radiation therapy (IMRT)
- Indication
- oropharyngeal cancer (OPC)
- Study design
- Cost-utility analysis; 7-state Markov model; outcome in QALYs; probabilistic sensitivity analysis, cohort analysis, tornado diagram and one-way sensitivity analyses
- Time horizon
- Lifetime horizon: 1-year Markov cycles from 1 year after radiotherapy to the estimated generalized Chinese life expectancy (77 years old, year 2020)
- Delivery technique
- IMPT (intensity-modulated proton radiation therapy)
- Perspective
- not reported by this study
- Currency
- US$
- Price year
- not reported by this study
- Willingness-to-pay threshold
- US$33,558/QALY (current WTP of China); scenarios at US$50,000/QALY and US$100,000/QALY
- Discount rate
- 3% annual rate for both costs and QALYs
- Cost of the particle course assumed
- US$50,000 per IMPT treatment course (current IMPT treatment cost); US$30,000 scenario also modelled
- Cost of the comparator assumed
- $12,000 per course of IMRT
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
Cost-effectiveness depends on the NTCP reduction achieved by IMPT (base case assumes 25%), patient age, IMPT treatment cost and WTP. At the current Chinese WTP and an IMPT cost of US$50,000, minimum NTCP reductions of 47.5%, 50.8%, 55.6%, 63.3% and 77.2% are needed for patients aged 10, 20, 30, 40 and 50 years. For a 56-year-old, lowering IMPT cost to US$30,000 reduces the minimum NTCP reduction from 91.4% to 44.6% at current WTP (from 69.0% to 33.5% at US$50,000/QALY; from 39.7% to 19.1% at US$100,000/QALY).
Capital cost assumption
- What it assumed
- No separate capital figure stated. The $50,000 IMPT charge is said to reflect both capital investment (building and infrastructure, hardware, dosimetry and engineering equipment, planning and management software, working capital during construction) and operating costs (land, equipment maintenance, electrical power, staff salaries). Alternative IMPT costs of $40,000 and $30,000 were also tested.
- Where that figure came from
- Charge standard applied at Shanghai Proton and Heavy Ion Center (Shanghai, China); IMRT cost of $12,000 referenced to Sun Yat-sen University Cancer Center (Guangzhou, China)
Reporting quality
74 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.