CORRESPONDENCE Re: E x a m in in g th e C o s tE ffe c tiv e n e s s o f R a d ia tio n T h e ra p y A m o n g O ld e r W o m e n W ith F a v o ra b le -R is k B re a s t C a n c e r T he treatment of breast cancer represents one of the most substantial expenditures for our health-care systems, and as such, changes in treatment have the ability to have a con siderable impact on spending for public and private health-care plans. Breast cancer radi otherapy represents one of the major costs of breast cancer treatment, and therefore, changes in radiation techniques can cause meaningful increases in the cost of treatment. Moving forward, new treatments and tech niques need to be evaluated not only for their clinical efficacy but also for their cost-efficacy compared with the current standard (1). W hen evaluating the cost-efficacy of new treatments, it is imperative to look beyond absolute cost differences, which can be misleading. In light of this, the study pre sented by Sen et al. is a welcome addition to the literature examining the cost-efficacy of breast radiotherapy techniques (2). This study is consistent with previous cost-effi cacy analyses, using ICERs (incremental cost-effectiveness ratio) and QALYs (quality adjust life year) as metrics, along with com monly used definitions of cost-efficacy. T he study used data from the CALGB (Cancer and Leukemia G roup B) that evaluated the omission of radiotherapy in low-risk elderly patients, as well as the Surveillance, Epidemiology, and End Results Registry, concluding that adjuvant radiotherapy is cost-effective for elderly patients but that newer radiotherapy techniques (intensitymodulated radiation therapy [IMRT] and brachytherapy) are not likely to be (3). T here are limitations to the analysis that impact its ability to guide clinicians in deciding on appropriate radiotherapy tech nique options for their patients. One key
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concern is that the new techniques were compared with no radiation therapy, which is not currently the standard of care in those undergoing breast-conserving therapy. Although the absolute benefit of radio therapy on local control may decrease with increasing age, the relative benefit does not, with clinicians often recommending radia tion therapy to elderly women with a good performance status (4). If we were to evalu ate the cost-efficacy of aromatase inhibitors in elderly breast cancer patients, would it be more important to compare the efficacy rel ative to tamoxifen or no endocrine therapy (5)? Another major concern is the omission of toxicities into the QALY assessment. It is unlikely that IM RT or brachytherapy will improve local control compared with tradi tional radiotherapy. However, prospective data does support that IM RT is associated with reduced acute and chronic toxicities, which would likely lead to improve qual ity of life, something not accounted for in the study. A previous study from our group evaluating the cost-efficacy of IM RT com pared with traditional radiotherapy found that IM RT is cost-effective (using the same standards as the Sen et al. study) when using toxicity data from randomized trials and more recent data using three-dimensional conformal radiotherapy (6). T his has also been demonstrated with brachytherapy compared with traditional radiotherapy (7). In conclusion, there is a growing need for more cost-efficacy data to help guide clinicians make cost-conscious decisions with regard to breast cancer radiother apy; however, this should n ot mean that patients, including elderly patients with shorter life expectancies, are denied new techniques based simply on higher absolute costs. Future analyses, to be practice chang ing, will need to incorporate quality-of-life parameters that account for improved tox icity profiles and reductions in treatm ent duration.
CHIRAG SHAH SAMEER BERRY FRANK A. VICIN1
R e fe r e n c e s
1. Hassett MJ, Elkin EB. W hat does breast cancer treatment cost and what is it worth? Hematol Oncol Clin North Am. 2013;27(4):829-841. 2. Sen S, Wang SY, Souios PR, et al. Examining the cost-effectiveness of radiation therapy among older women with favorable-risk breast cancer. JN C IJ Natl Cancer Inst (2014) 106(3): dju008 doi:10.1093/jnci/dju008. 3. Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irra diation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343.7 C®» Oncol. 2013;31(19):2382-2387. 4. Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgeiy on 10-year recurrence and 15-year breast can cer death: meta-analysis of individual patient data for 10,801 women in 17 randomised tri als. Lancet. 2011;378(9804): 1707-1716. 5. Frederix GW, Severens JL, Hovels AM, et al. Reviewing the cost-effectiveness of endocrine early breast cancer therapies: influence of dif ferences in modeling methods and outcomes. Value Health. 2012;15(1):94-105. 6. Sittig MP, Badiyan S, Zoberi I. Intensity modu lated radiation therapy represents a cost-effective modality to deliver whole breast irradiation: a toxicity analysis. Paper presented at 55th annual meeting of the American Society of Radiation Oncology; September 2013; Adanta, GA. 7. Shah C, Lanni TB, Saini H, et al. Cost-efficacy of accelerated partial breast irradiation com pared with whole-breast irradiation. Breast Cancer Res Treat. 2013;138(1):127—135. N o te s The authors have no conflicts o f interest to disclose.
Affiliations of authors: Departm ent o f Radiation Oncology, Sum m a Health System, Akron, OH (CS, SB); Michigan Healthcare P ro fe s s io n a ls ^ ” Century Oncology, Farm ington Hills, M l (FAV).
Correspondence to: Chirag Shah, MD, Department o f Radiation Oncology, Summa Health System, Akron, OH 44304 (e-mail: csshah27@ hotm ail.com ).
DOI:10.1093/j nci/dju 134 First published online M ay 30, 2014 ©The A u th o r 2014. Published by O xford U niversity Press. A ll rights reserved. For Permissions, please e-mail: journals.perm issions@ oup.com .
Vol. 106, Issue 6 | d ju 1 3 4 | Ju n e 11,2014
Copyright of JNCI: Journal of the National Cancer Institute is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
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Correspondence
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concern is that the new techniques were compared with no radiation therapy, which is not currently the standard of care in those undergoing breast-conserving therapy. Although the absolute benefit of radio therapy on local control may decrease with increasing age, the relative benefit does not, with clinicians often recommending radia tion therapy to elderly women with a good performance status (4). If we were to evalu ate the cost-efficacy of aromatase inhibitors in elderly breast cancer patients, would it be more important to compare the efficacy rel ative to tamoxifen or no endocrine therapy (5)? Another major concern is the omission of toxicities into the QALY assessment. It is unlikely that IM RT or brachytherapy will improve local control compared with tradi tional radiotherapy. However, prospective data does support that IM RT is associated with reduced acute and chronic toxicities, which would likely lead to improve qual ity of life, something not accounted for in the study. A previous study from our group evaluating the cost-efficacy of IM RT com pared with traditional radiotherapy found that IM RT is cost-effective (using the same standards as the Sen et al. study) when using toxicity data from randomized trials and more recent data using three-dimensional conformal radiotherapy (6). T his has also been demonstrated with brachytherapy compared with traditional radiotherapy (7). In conclusion, there is a growing need for more cost-efficacy data to help guide clinicians make cost-conscious decisions with regard to breast cancer radiother apy; however, this should n ot mean that patients, including elderly patients with shorter life expectancies, are denied new techniques based simply on higher absolute costs. Future analyses, to be practice chang ing, will need to incorporate quality-of-life parameters that account for improved tox icity profiles and reductions in treatm ent duration.
CHIRAG SHAH SAMEER BERRY FRANK A. VICIN1
R e fe r e n c e s
1. Hassett MJ, Elkin EB. W hat does breast cancer treatment cost and what is it worth? Hematol Oncol Clin North Am. 2013;27(4):829-841. 2. Sen S, Wang SY, Souios PR, et al. Examining the cost-effectiveness of radiation therapy among older women with favorable-risk breast cancer. JN C IJ Natl Cancer Inst (2014) 106(3): dju008 doi:10.1093/jnci/dju008. 3. Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irra diation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343.7 C®» Oncol. 2013;31(19):2382-2387. 4. Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgeiy on 10-year recurrence and 15-year breast can cer death: meta-analysis of individual patient data for 10,801 women in 17 randomised tri als. Lancet. 2011;378(9804): 1707-1716. 5. Frederix GW, Severens JL, Hovels AM, et al. Reviewing the cost-effectiveness of endocrine early breast cancer therapies: influence of dif ferences in modeling methods and outcomes. Value Health. 2012;15(1):94-105. 6. Sittig MP, Badiyan S, Zoberi I. Intensity modu lated radiation therapy represents a cost-effective modality to deliver whole breast irradiation: a toxicity analysis. Paper presented at 55th annual meeting of the American Society of Radiation Oncology; September 2013; Adanta, GA. 7. Shah C, Lanni TB, Saini H, et al. Cost-efficacy of accelerated partial breast irradiation com pared with whole-breast irradiation. Breast Cancer Res Treat. 2013;138(1):127—135. N o te s The authors have no conflicts o f interest to disclose.
Affiliations of authors: Departm ent o f Radiation Oncology, Sum m a Health System, Akron, OH (CS, SB); Michigan Healthcare P ro fe s s io n a ls ^ ” Century Oncology, Farm ington Hills, M l (FAV).
Correspondence to: Chirag Shah, MD, Department o f Radiation Oncology, Summa Health System, Akron, OH 44304 (e-mail: csshah27@ hotm ail.com ).
DOI:10.1093/j nci/dju 134 First published online M ay 30, 2014 ©The A u th o r 2014. Published by O xford U niversity Press. A ll rights reserved. For Permissions, please e-mail: journals.perm issions@ oup.com .
Vol. 106, Issue 6 | d ju 1 3 4 | Ju n e 11,2014
Copyright of JNCI: Journal of the National Cancer Institute is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
