Upfront treatment of locally advanced cervical cancer with intensity modulated radiation therapy compared to four-field radiation therapy: a cost-effectiveness analysis

Abstract

Objective: Radiation can be delivered via four-field box (BOX-RT) or intensity modulated radiation therapy (IMRT). We sought to evaluate the cost-effectiveness (C/E) of IMRT relative to BOX-RT for the treatment of locally advanced cervical cancer.

Methods: A three-year Markov model with eight-week cycles was developed to compare IMRT to BOX-RT. A proportion (25%) received extended-field radiation therapy (EFRT) to include para-aortic nodes. The model assumed equal overall survival (OS). The model captured costs and utility estimates for BOX-RT, IMRT, and each complication. Modeled complications included acute and chronic toxicities. Baseline model assumptions were obtained by literature review and supplemented by expert opinion. Costs were based on Medicare reimbursement rates and the Agency for Healthcare Research and Quality Database. Treatment strategies were compared using an incremental cost-effectiveness ratio (ICER). One-way, probabilistic and structural sensitivity analyses were performed to account for uncertainty in assumptions. The C/E of each strategy was evaluated from the perspective of the health care system.

Results: C/E analysis revealed an ICER for IMRT of $182,777/quality adjusted life year (QALY) gained. Although this value was higher than the willingness to pay threshold of $100,000/QALY, sensitivity analysis revealed several modifications that would make IMRT a C/E option relative to BOX-RT. For patients requiring EFRT, IMRT was C/E with an ICER of $91,580/QALY.

Conclusions: Although IMRT was not C/E at the $100,000 willingness-to-pay threshold, in those requiring EFRT, IMRT was C/E relative to BOX-RT. A randomized trial comparing IMRT to BOX-RT for the treatment of locally advanced cervical cancer is warranted.