BACKGROUND It is currently unclear if the superior normal organ sparing effect of Intensity Modulated Radiation Therapy (IMRT) as compared to three-dimensional radiation therapy (3D) has clinical impact on survival and cardiopulmonary mortality in esophageal cancer (EC) patients. METHODS We identified 2,553 patients older than age 65 years from the SEER/Texas Cancer Registry-Medicare databases who had non-metastatic EC diagnosed between 2002 and 2009 and were treated with either 3D (n=2,240) or IMRT (n=313) within 6 months of diagnosis. The outcomes of the two cohorts were compared using Inverse Probability of Treatment Weighting (IPTW) adjustment. RESULTS Except for marital status, year of diagnosis, and SEER region, both radiation cohorts were well balanced for various patient, tumor, and treatment characteristics, including the use of IMRT vs. 3D in urban/metro or rural areas. IMRT use increased from 2.6% in 2002 to 30% in 2009, while 3D use decreased from 97.4% in 2002 to 70% in 2009. On propensity score IPTW-adjusted multivariate analysis, IMRT was not associated with EC-specific mortality (HR 0.93, 95%CI 0.80-1.10) or pulmonary mortality (HR 1.11, 95%CI 0.37-3.36) but was significantly associated with lower all-cause mortality (HR 0.83, 95%CI 0.72-0.95), cardiac mortality (HR 0.18, 95%CI 0.06-0.54) and other cause mortality (HR 0.54, 95%CI 0.35-0.84). Similar associations were seen after adjusting for the type of chemotherapy, physician experience, and sensitivity analysis removing hybrid radiation claims. CONCLUSIONS In this population-based analysis, IMRT use was significantly associated with lower all-cause mortality, cardiac mortality, and other-cause mortality in EC patients.

PurposeModerately hypofractionated intensity modulated radiation therapy (HIMRT) for prostate cancer shortens the treatment course while providing outcomes comparable with those of conventional intensity modulated radiation therapy (CIMRT). To determine the long-term economic value of HIMRT, including the costs of managing long-term radiation toxicities, a cost minimization analysis compared CIMRT with dose-escalated HIMRT using patient-level data from a randomized trial.Methods and materialsMen with localized prostate cancer were randomized to CIMRT (75.6 Gy in 42 fractions over 8.4 weeks) or HIMRT (72 Gy in 30 fractions over 6 weeks). A decision tree modeled trial probabilities of maximum late bowel and urinary toxicities using patient-level data with a median follow-up of 6 years. Costs were estimated from the healthcare perspective using the 2014 national reimbursement rates for services received. Patient-level institutional costs, adjusted to 2014 dollars, verified reimbursements. A sensitivity analysis assessed model uncertainty.ResultsThe cost for HIMRT and toxicity management was $22,957, saving $7,000 compared with CIMRT ($30,241). CIMRT was the common factor among the 5 most influential scenarios that contributed to total costs. Toxicity represented a small part (<10%) of the average total cost for patients with either grade 2-3 bowel toxicity or grade 2-3 urinary toxicity. However, toxicity management reached up to 26% of the total cost for patients with both high-grade bowel and urinary toxicities. There was no threshold at which CIMRT became the less costly regimen. Institutional costs confirmed the economic value of HIMRT ($6,000 in savings).ConclusionsHIMRT is more cost-efficient than CIMRT for treating prostate cancer, even when taking into account the costs related to late radiation toxicities. HIMRT enhances the value of prostate radiation when compared with CIMRT.

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The objective was to identify clinical and epidemiological factors associated with utilization of a complex oral treatment device (COTD), which may decrease toxicity in patients undergoing radiation therapy for head and neck cancer (HNC). Materials and Methods: We retrospectively reviewed data from 1992 to 2013 in the Surveillance, Epidemiology, and End Results (SEER)-Medicare databases to analyze COTD usage during intensity-modulated radiation therapy (IMRT) for patients diagnosed with cancer of the tongue, floor of mouth, nasopharynx, tonsil, or oropharynx. Patients with a radiation simulation and complex treatment device code within 4 weeks before the first IMRT claim were identified as meeting COTD usage criteria. Demographic, regional, tumor, and treatment data were analyzed. Results: Out of 4511 patients who met eligibility criteria, 1932 patients (42.8%) did not utilize a COTD while 2579 (57.2%) met usage criteria. COTD utilization increased over time (36.36% usage in 1992 vs. 67.44% usage in 2013, p < .0001). Patients less likely to receive a COTD included those aged 86 years or older compared to those aged 66-70 (OR = 0.713, 95% CI: 0.528-0.962), male patients (OR = 0.817, 95% CI: 0.710-0.941), non-Hispanic Black patients compared to non-Hispanic White patients (OR = 0.750, 95% CI: 0.582-0.966), and Louisiana residents (OR = 0.367, 95% CI: 0.279-0.483). Cancer site, grade, stage, or function of IMRT had no significant association with COTD usage. Conclusions: This study serves as the first known SEER-Medicare review of COTD utilization. Despite an increase in COTD usage over time, our results indicate age, gender, and geographic disparities are associated with utilization. Further research and development into methods that increase availability of COTDs may help increase utilization in specific patient populations.

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