A Cost-Effectiveness Study of Stereotactic-Body Radiation Therapy Compared to Surgery in Patients with Early Non-Small Cell Lung Cancer, from the Perspective of the Brazilian Private Health-Care System

Abstract

<h3>Purpose/Objective(s)</h3> The standard of care for operable stage I non-small cell lung cancer (NSCLC) is lobectomy with mediastinal lymph node dissection. Stereotactic body radiotherapy (SBRT) has shown promising results in non-operable patients. Previous randomized trials, comparing those technologies, were closed early due to poor accrual, but pooled results have indicated that they are, at least, equally effective. Further trials were opened, and results are waited for the following years to come. The objective of this study was to evaluate the cost-effectiveness of SBRT, compared to lobectomy, in operable stage I NSCLC. <h3>Materials/Methods</h3> A Markov model was built based on the pooled analysis of two previous prospective randomized trials. Costs, in reais (BRL), were extracted from the database of a Brazilian nationwide health care provider (Capesesp). Utility values, recurrence, and death probabilities were adapted from the literature. The analysis was conducted from the Brazilian healthcare private system perspective. A 10 years' time horizon was used in the study. A yearly discount rate of 5% was applied, according to Brazilian regulatory authorities' recommendations. Deterministic (DSA) and probabilistic sensitivity analysis (PSA) were performed to evaluate the influence on the results of the assumptions that were made. <h3>Results</h3> SBRT and lobectomy total costs were 93,207.00 and 115,776.00 BRL and utilities were 2.72 and 2.55 QALYs (quality-adjusted life-years), respectively, showing that SBRT was dominant over surgery, with an incremental cost-effectiveness ratio (ICER) of -134,445.27 BRL. The DSA, performed based on every made assumption, showed that results depended mainly on the probability of progression after lobectomy, on the cost of chemotherapy, prescribed for patients that presented progression after both curative treatments, and on the probability of recurrence after SBRT. PSA revealed that SBRT had a considerably higher probability of being cost-effective, compared to lobectomy. <h3>Conclusion</h3> our results indicate that for patients with stage I, operable, NSCLC, SBRT is probably dominant over lobectomy. Sensitivity analysis has shown that those results are robust and not modified by the assumptions that were made during the construction of the model. It raises the importance of the open trials comparing those technologies, once SBRT can be a viable cost-saving option, in our environment, if its effectiveness is proven to be, at least, comparable to surgery.