BACKGROUND:The traditional treatment for clearly operable (CO) patients with stage I non-small cell lung cancer (NSCLC) is lobectomy, with wedge resection (WR) and stereotactic body radiation therapy (SBRT) serving as alternatives in marginally operable (MO) patients. Given an aging population with an increasing prevalence of screening, it is likely that progressively more people will be diagnosed with stage I NSCLC, and thus it is critical to compare the cost-effectiveness of these treatments. METHODS: A Markov model was created to compare the cost-effectiveness of SBRT with WR and lobectomy for MO and CO patients, respectively. Disease, treatment, and toxicity data were extracted from the literature and varied in sensitivity analyses. A payer (Medicare) perspective was used. RESULTS: In the base case, SBRT (MO cohort), SBRT (CO cohort), WR, and lobectomy were associated with mean cost and quality-adjusted life expectancies of $42,094/8.03, $40,107/8.21, $51,487/7.93, and $49,093/8.89, respectively. In MO patients, SBRT was the dominant and thus cost-effective strategy. This result was confirmed in most deterministic sensitivity analyses as well as probabilistic sensitivity analysis, in which SBRT was most likely cost-effective up to a willingness-to-pay of more than $500,000/quality-adjusted life year. For CO patients, lobectomy was the cost-effective treatment option in the base case (incremental cost-effectiveness ratio of $13,216/quality-adjusted life year) and in nearly every sensitivity analysis. CONCLUSIONS: SBRT was nearly always the most cost-effective treatment strategy for MO patients with stage I NSCLC. In contrast, for patients with CO disease, lobectomy was the most cost-effective option. Cancer 2013;119:3123-32. V C 2013 American Cancer Society.KEYWORDS: lung cancer; cost-effectiveness; stereotactic body radiation therapy; surgery; lobectomy; wedge resection.
INTRODUCTIONLung cancer is the leading cause of cancer mortality in the United States and, given the positive results of the National Lung Screening Trial (NLST), 1 it is likely that more people will be diagnosed with early-stage lung cancer in future years. The traditional treatment for patients with stage I non-small cell lung cancer (NSCLC) is lobectomy. Sublobar resection (eg, wedge resection) or ablation are often performed as an alternative to lobectomy in patients with smaller, peripheral tumors and compromised lung function. Sublobar resection has traditionally been considered inferior to anatomic lobectomy, although prospective multicenter trials are underway.For patients who are medically inoperable, stereotactic body radiation therapy (SBRT) has effectively emerged as the standard-of-care treatment. SBRT combines precise patient localization with highly conformal treatment delivery, allowing high-dose treatment in 1 to 2 weeks (usually 10 to 18 Gy per treatment for 3 to 5 sessions). Compared with conventional radiation therapy, prospective experience with SBRT has demonstrated improved local control and survival in the setting of ...