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Cost-Effectiveness of Adding an Electron-Beam Boost to Tangential Radiation Therapy in Patients With Negative Margins After Conservative Surgery for Early-Stage Breast Cancer

From the Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, Medical College of Virginia Campus of the Virginia Commonwealth University, Richmond, VA; Department of Radiation Oncology, Brigham and Women’s Hospital and Dana-Farber Cancer Institute; and Center for Outcomes and Policy Research, Department of Adult Oncology, Dana-Farber Cancer Institute, Boston, MA.

Address reprint requests to James A. Hayman, MD, Department of Radiation Oncology, University of Michigan Medical Center, UH B2C490, Box 0010, 1500 East Medical Center Dr, Ann Arbor, MI, 48109-0010; email hayman{at}umich.edu

PURPOSE: Electron-beam boosts (EBB) are routinely added after conservative surgery and tangential radiation therapy (TRT) for early-stage breast cancer. We performed an incremental cost-utility analysis to evaluate their cost-effectiveness.

METHODS: A Markov model examined the impact of adding an EBB to TRT from a societal perspective. Outcomes were measured in quality-adjusted life years (QALYs). On the basis of the Lyon trial, the EBB was assumed to reduce local recurrences by approximately 2% at 10 years but to have no impact on survival. Patients’ utilities were used to adjust for quality of life. Given the small absolute benefit of the EBB, baseline utilities were assumed to be the same with or without it, an assumption evaluated by Monte Carlo simulation. Direct medical, time, and travel costs were considered.

RESULTS: Adding the EBB led to an additional cost of $2,008, an increase of 0.0065 QALYs and, therefore, an incremental cost-effectiveness ratio of over $300,000/QALY. In a sensitivity analysis, the ratio was moderately sensitive to the efficacy and cost of the EBB and highly sensitive to patients’ utilities for treatment without it. Even if patients do value a small risk reduction, the mean cost-effectiveness ratio estimated by the Monte Carlo simulation remains high, at $70,859/QALY (95% confidence interval, $53,141 to $105,182/QALY).

CONCLUSION: On the basis of currently available data, the cost-effectiveness ratio for the EBB is well above the commonly cited threshold for cost-effective care ($50,000/QALY). The EBB becomes cost-effective only if patients place an unexpectedly high value on the small absolute reduction in local recurrences achievable with it.

Dr Hayman is a recipient of a Clinical Research Training Grant for Junior Faculty from the American Cancer Society.

Presented at the Thirty-Fourth Annual Meeting of the American Society of Clinical Oncology, Los Angeles, CA, May 16-19, 1998.

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