Cost-effectiveness of stereotactic radiosurgery with and without whole-brain radiotherapy for the treatment of newly diagnosed brain metastases

Abstract

ObjectStereotactic radiosurgery (SRS) alone is increasingly used in patients with newly diagnosed brain metastases. Stereotactic radiosurgery used together with whole-brain radiotherapy (WBRT) reduces intracranial failure rates, but this combination also causes greater neurocognitive toxicity and does not improve survival. Critics of SRS alone contend that deferring WBRT results in an increased need for salvage therapy and in higher costs. The authors compared the cost-effectiveness of treatment with SRS alone, SRS and WBRT (SRS+WBRT), and surgery followed by SRS (S+SRS) at the authors' institution.MethodsThe authors retrospectively reviewed the medical records of 289 patients in whom brain metastases were newly diagnosed and who were treated between May 2001 and December 2007. Overall survival curves were plotted using the Kaplan-Meier method. Multivariate proportional hazards analysis (MVA) was used to identify factors associated with overall survival. Survival data were complete for 96.2% of patients, and comprehensive data on the resource use for imaging, hospitalizations, and salvage therapies were available from the medical records. Treatment costs included the cost of initial and all salvage therapies for brain metastases, hospitalizations, management of complications, and imaging. They were computed on the basis of the 2007 Medicare fee schedule from a payer perspective. Average treatment cost and average cost per month of median survival were compared. Sensitivity analysis was performed to examine the impact of variations in key cost variables.ResultsNo significant differences in overall survival were observed among patients treated with SRS alone, SRS+WBRT, or S+SRS with respective median survival of 9.8, 7.4, and 10.6 months. The MVA detected a significant association of overall survival with female sex, Karnofsky Performance Scale (KPS) score, primary tumor control, absence of extracranial metastases, and number of brain metastases. Salvage therapy was required in 43% of SRS-alone and 26% of SRS+WBRT patients (p < 0.009). Despite an increased need for salvage therapy, the average cost per month of median survival was $2412 per month for SRS alone, $3220 per month for SRS+WBRT, and $4360 per month for S+SRS (p < 0.03). Compared with SRS+WBRT, SRS alone had an average incremental cost savings of $110 per patient. Sensitivity analysis confirmed that the average treatment cost of SRS alone remained less than or was comparable to SRS+WBRT over a wide range of costs and treatment efficacies.ConclusionsDespite an increased need for salvage therapy, patients with newly diagnosed brain metastases treated with SRS alone have similar overall survival and receive more cost-effective care than those treated with SRS+WBRT. Compared with SRS+WBRT, initial management with SRS alone does not result in a higher average cost.

Prediction of new brain metastases after radiosurgery: validation and analysis of performance of a multi-institutional nomogram

“…Other factors including local failure risk, life expectancy, leptomeningeal involvement, current cognitive function and practitioner bias contribute to this decision. Despite these other factors, DBF is an endpoint that significantly affects the cost of future care as it can lead to multiple salvage treatments given its prevalence and the cost of multiple SRS procedures [1, 2]. The use of salvage WBRT after SRS ranged from 5 to 20% amongst the SRS centers in the current study, suggesting that the standards for use of WBRT vary amongst institutions.…”

“…Salvage therapies for the management of distant brain failure (DBF) following initial stereotactic radiosurgery (SRS) monotherapy, can have a substantial impact on medical cost-effectiveness [1]. SRS is approximately four-fold more expensive than whole brain radiotherapy (WBRT) but has been proven to be more cost-effective in selected patient populations [2, 3].…”

Cost-effectiveness of stereotactic radiosurgery versus whole-brain radiation therapy for up to 10 brain metastases

“…15 A retrospective by Hall et al reviewed the records of 289 patients treated with SRS or SRS+WBRT to determine both survival outcomes and Medicare reimbursement for all treatments incurred and found that SRS was the most cost-effective option. 13 However, only 14% of patients in this study treated with SRS alone had more than 4 brain metastases.…”

Radiosurgery for Patients with More Than Ten Brain Metastases

“…Therefore, the addition of WBRT did not always improve the overall survival or reduce the average total treatment cost. This indicates that radiosurgery might be useful not only in terms of tumor control but also in terms of cost-effectiveness [6]. Some studies have postulated treatment strategies using hypo-fraction or staged methods as well [7,8].…”