Background: Prior cost-effectiveness studies of post-mastectomy radiotherapy (PMRT) only compared conventional radiotherapy versus no radiotherapy and only considered tumor control. The goal of this study was to perform cost-effectiveness analyses of standard of care (SOC) and advanced PMRT techniques including intensity-modulated radiotherapy (IMRT), standard volumetric modulated arc therapy (STD-VMAT), non-coplanar VMAT (NC-VMAT), multiple arc VMAT (MA-VMAT), Tomotherapy (TOMO), mixed beam therapy (MIXED), and intensity-modulated proton therapy (IMPT).Methods: Using a Markov model, we estimated the cost-effectiveness of various techniques over 15 years. A cohort of women (55-year-old) was simulated in the model, and radiogenic side effects were considered. Transition probabilities, utilities, and costs for each health state were obtained from literature and Medicare data. Model outcomes include quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER), and SOC was used as the reference.Results: For the patient cohort, IMRT is the most cost-effective technique with an ICER value of 27,310 $/QALY, and IMPT has the highest ICER of 74,564 $/QALY. One-way analysis shows that the probability of cardiac toxicity has the most significant impact on the model outcomes. The probability sensitivity analyses show that all advanced PMRT techniques are more cost-effective than SOC at a willingness-to-pay (WTP) threshold of 100,000 $/QALY, while almost none of the advanced techniques is more cost-effective than SOC at a WTP threshold of $50,000/QALY.Conclusion: Advanced PMRT techniques are more cost-effective for breast cancer patients at a WTP threshold of 100,000 $/QALY, and IMRT might be the most cost-effective option for PMRT patients.
Recent success of sequential administration of immunotherapy following radiotherapy (RT), often referred to as immunoRT, has sparked the urgent need for novel clinical trial designs to accommodate the unique features of immunoRT. For this purpose, we propose a Bayesian phase I/II design for immunotherapy administered after standard‐dose RT to identify the optimal dose that is personalized for each patient according to his/her measurements of PD‐L1 expression at baseline and post‐RT. We model the immune response, toxicity, and efficacy as functions of dose and patient's baseline and post‐RT PD‐L1 expression profile. We quantify the desirability of the dose using a utility function and propose a two‐stage dose‐finding algorithm to find the personalized optimal dose. Simulation studies show that our proposed design has good operating characteristics, with a high probability of identifying the personalized optimal dose.
Objective. Feasibility of three-dimensional (3D) tracking of volumetric modulated arc therapy (VMAT) based on VMAT–computed tomography (VMAT-CT) has been shown previously by our group. However, 3D VMAT-CT is not suitable for treatments that involve significant target movement due to patient breathing. The goal of this study was to reconstruct four-dimensional (4D) VMAT-CT and evaluate the feasibility of tracking based on 4D VMAT-CT. Approach. Synchronized EPID images of phantoms and linac log were both sorted into four phases, and VMAT-CT+ was generated in each phase by fusing reconstructed VMAT-CT and planning CT using rigid or deformable registration. Dose was calculated in each phase and was registered to the mean position planning CT for 4D dose reconstruction. Trackings based on 4D VMAT-CT+ and 4D cone beam CT (CBCT) were compared. Potential uncertainties were also evaluated. Main results. Tracking based on 4D VMAT-CT+ was accurate, could detect phantom deformation and/or change of breathing pattern, and was superior to that based on 4D CBCT. The impact of uncertainties on tracking was minimal. Significance. Our study shows it is feasible to accurately track position and dose based on 4D VMAT-CT for patients whose VMAT treatments are subject to respiratory motion. It will significantly increase the confidence of VMAT and is a clinically viable solution to daily patient positioning, in vivo dosimetry and treatment monitoring.
Background: Prior cost-effectiveness studies of post-mastectomy radiotherapy (PMRT) only compared conventional radiotherapy versus no radiotherapy and only considered tumor control. The goal of this study was to perform cost-effectiveness analyses of standard of care (SOC) and advanced PMRT techniques including intensity-modulated radiotherapy (IMRT), standard volumetric modulated arc therapy (STD-VMAT), non-coplanar VMAT (NC-VMAT), multiple arc VMAT (MA-VMAT), Tomotherapy (TOMO), mixed beam therapy (MIXED), and intensity-modulated proton therapy (IMPT). Methods: Using a Markov model, we estimated the cost-effectiveness of various techniques over 15 years. A cohort of women (55-year-old) was simulated in the model, and radiogenic side effects were considered. Transition probabilities, utilities, and costs for each health state were obtained from literature and Medicare data. Model outcomes include quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER). Results: For the patient cohort, STD-VMAT has ICER of $32,617 relative to SOC; TOMO is dominated by STD-VMAT; IMRT has ICER of 19,081 $/QALY relative to STD-VMAT; NC-VMAT, MA-VMAT, MIXED are dominated by IMRT; IMPT has ICER of 151,741 $/QALY relative to IMRT. One-way analysis shows that the probability of cardiac toxicity has the most significant impact on the model outcomes. The probability sensitivity analyses show that all advanced PMRT techniques are more cost-effective than SOC at a willingness-to-pay (WTP) threshold of 100,000 $/QALY, while almost none of the advanced techniques is more cost-effective than SOC at a WTP threshold of $50,000/QALY. Conclusion: Advanced PMRT techniques are more cost-effective for breast cancer patients at a WTP threshold of 100,000 $/QALY, and IMRT might be a cost-effective option for PMRT patients.
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