Cost-effectiveness of stereotactic radiosurgery versus whole brain radiation therapy for up to 10 brain metastases

Transcription

1 Cost-effectiveness of stereotactic radiosurgery versus whole brain radiation therapy for up to 10 brain metastases Nataniel H. Lester-Coll, MD, Arie P. Dosoretz, MD, MBA, Maxwell S. Laurans, MD, Veronica Chiang, MD, James B. Yu, MD, MHS S L I D E 0

2 Disclosures Dr. Lester-Coll received an honorarium from Elekta AB, unrelated to the current work. Dr. Yu receives research funding from 21st Century Oncology LLC, unrelated to the current work. S L I D E 1

3 Background Whole brain radiation therapy (WBRT) used to treat brain metastases (BM) Effective but concerns for toxicity 3 randomized trials evaluated stereotactic radiosurgery (SRS) for 1-4 BM MD Anderson (Chang et al) Japanese (Aoyama et al) EORTC (Kocher et al) All three showed similar results intracranial control and salvage with WBRT Improved quality-of-life outcomes with SRS S L I D E 2

4 Background S L I D E 3

5 Background What about treating more than 3-4 metastases? What about costs? SRS without WBRT in patients with 5-10 brain metastases is non-inferior to that in patients with two-four brain metastases. S L I D E 4

6 Abbreviated decision tree and Markov model S L I D E 5

7 Endpoints Costs in USD ($) Effectiveness in Quality-Adjusted Life Years (QALY) Incremental Cost-Effectiveness Ratio (ICER) CCCCCCCC 1 CCCCCCCC 0 QQQQQQQQ 1 QQQQQQQQ 0 S L I D E 6

8 Influence diagram 0.84 SRS 0.75 WBRT Stable Intracranial progression Neurologic death Dead 0.50 Radionecrosis 0.30 Neurocognitive decline S L I D E 7

9 Probability Modeling Target data: JLGK0901 Rates of local control, intracranial failure, neurotoxicity and salvage SRS modified based on RTOG 9508 and EORTC S L I D E 8

10 Costs: Medicare Fees SRS (1x) $13,389 WBRT (1x) $4,949 Craniotomy (1x) $21,828 MRI of the brain (every 1.5 or 3 months) $778 Progression (monthly) $6,055 Death (1x) $5,389 S L I D E 9

11 1 BM S L I D E 10

12 1 BM S L I D E 11

13 1 BM S L I D E 12

14 2-10 BM S L I D E 13

15 2-10 BM S L I D E 14

16 2-10 BM S L I D E 15

17 2-10 BM: SRS v WBRT S L I D E 16

18 2-10 BM $130,000 S L I D E 17

19 How much are we willing to pay? Some economists as well as the World Health Organization have argued, on the basis of plausible assumptions about people s values and attitudes toward risk, for a threshold of two to three times the per capita annual income, which would imply a U.S. threshold of $110,000 to $160,000 per QALY today (given that the per capita income is roughly $54,000). Others have inferred a threshold of $200,000 to $300,000 per QALY on the basis of increases in health care spending over time and the health gains that have been associated with those increases, surveys that ask people how much they would be willing to pay for health gains, or the trade-offs that people make in the workplace between pay and safety risks. S L I D E 18

20 How much are we willing to pay? 498 respondents, representative of the Dutch population, participated in the survey. Mean WTP per QALY was 65,797 based on Dutch EQ-5D tariffs and 65,194 based on VAS valuations. Incorporating discounting and a correction for age-related quality of life decline lead to much higher WTP estimates. WTP for a QALY was strongly associated with income, varying from an average of 43,611 (EQ-5D) and 43,211 (VAS) in the lowest income group to an average of 84,505 (EQ-5D) and 83,730 (VAS) in the highest income group. S L I D E 19

21 Highlights 1 SRS v WBRT+SRS ICER is $51,348 - $58,903 per QALY 2 SRS v WBRT ICER is $117,418 - $123,256 per QALY 3 WBRT+SRS v WBRT ICER is $746,997 - $821,042 per QALY S L I D E 20

22 Acknowledgements Arie P. Dosoretz, MD, MBA Maxwell S. Laurans, MD Veronica Chiang, MD James B. Yu, MD, MHS S L I D E 21

23 Questions? Nataniel H. Lester-Coll, M.D. PGY-4 Department of Therapeutic Radiology Yale School of Medicine New Haven, CT S L I D E 22

24 Appendix Slides Table 1: Model Parameters and Assumptions Base Case and Modeled Distribution (IQ Range) Variable 1 BM 2-10 BM Reference Transition probabilities: β distributed Progression from stable state ( ) ( ) Yamamoto et al. Death from stable state ( ) ( ) Yamamoto et al. Death from progression state ( ) ( ) Yamamoto et al. Salvage SRS 0.33 ( ) 0.43 ( ) Yamamoto et al. Neurologic death 0.10 ( ) 0.04 ( ) Yamamoto et al. Probability of neurocognitive decline ( ) ( ) Yamamoto et al. Probability of radionecrosis ( ) Yamamoto et al. Hazard ratio for the Impact of SRS boost on local control: γ distributed 1.20 (0.60 1) Andrews et al. Hazard ratios for the impact of WBRT on outcomes: γ distributed Intracranial failure 0.61 ( ) Kocher et al. Salvage SRS 0.31 ( ) Kocher et al. Neurocognitive decline 1.55 ( ) Kocher et al. Utilities: β distributed Stable after SRS 0.85 ( ) Lester-Coll et al. WBRT 0.70 ( ) Lester-Coll et al. Progression 0.55 ( ) Lester-Coll et al. Neurologic death 0.25 ( ) Lester-Coll et al. Radionecrosis 0.50 ( ) Lester-Coll et al. Neurocognitive decline 0.30 ( ) Lester-Coll et al. Costs: γ distributed SRS $13,389 ($10,042 $16,737) Institutional Medicare Fees WBRT $4,949 ($3,712 $6,186) Institutional Medicare Fees Craniotomy $21,828 ($16,371 $27,285) Institutional Medicare Fees MRI of the brain $778 ($584 $973) Institutional Medicare Fees Progression $6,055 ($4,541 $7,569) Obermeyer et al. Death $5,389 ($4,042 $6,736) Obermeyer et al. S L I D E 23

25 Appendix Slides Table 2: Internal Validation Internal validation metric Model Yamamoto et al. Clinical Data 1 BM OS at 1, 2 years 59%, 33% 55%, 33% PFS at 1, 2 years 50%, 25% 44%, 26% Neurologic deaths 10% 10% Neurocognitive decline 6% 6% Radionecrosis 1% 1% 2-10 BM OS at 1, 2 years 49%, 26% 47%, 26% PFS at 1, 2 years 33%, 11% 30%, 18% Neurologic deaths 10% 9% Neurocognitive decline 10% 10% Radionecrosis 1% 1% S L I D E 24

26 Appendix Slides 1 BM Threshold = 4.7% OS S L I D E 25

27 Appendix Slides 2 BM Threshold = 1.5% OS S L I D E 26