Comparison and Breakdown of Cost in Head and Neck Cancer Radiation Therapy and Adaptive Replanning

Abstract

Head and neck cancers pose a significant challenge to radiation oncologists due to several factors, including rapid shrinkage during radiation and patient weight loss. As the target and patient anatomy change, re-simulation and re-planning are often necessary, which precipitates additional time, resources, and cost. However, the true added cost of providing adaptive replanning for head and neck cancer patients receiving radiation therapy (RT) is often unknown. We hypothesize that adaptive replanning adds significant cost to treatment, primarily driven by the additional personnel time in the replanning process. The total costs of providing standard radiation therapy and treatment with adaptive replanning for head and neck cancer were calculated using time-driven activity-based costing. We created process maps for each step from consultation to end of treatment, utilizing data that included the space, personnel involved, equipment and supplies used, and time spent. Capacity cost rates were calculated for all resources using a combination of publicly accessible cost data, financial data from our institution, and time averages for each activity obtained from personnel interviews and clinical measurements. We included the following domains in our process maps: consultation, CT simulation, treatment planning, new treatment start, daily beam treatments, weekly on-treatment visits, CT Re-simulation, treatment replanning, and new start for replanned treatment. We found that the total cost for providing standard therapy was $12,216.39 US Dollars (USD), while the total cost of adaptive replanning was $14,705.14 USD, for a relative increase in cost of 20.4%. The most expensive factor for both treatment arms was the cost of daily treatments on the linear accelerator, representing 66.1% and 53.3% of the standard and adaptive replanning, respectively. The second largest driver of cost for both was weekly on-treatment visits with a physician, representing 11.37% and 9.45% of the total cost, respectively. Of the total cost difference between standard therapy and adaptive replanning, 64% was due to personnel costs, 27.9% was due to space/equipment costs, and 8.1% was attributable to material costs. We found that adaptive replanning increased the overall cost of radiotherapy for head and neck cancers by a significant amount. The additional personnel time with resim and replanning, as well as machine time on the CT simulator are the primary reasons for this increase. In addition, use of these resources represents an opportunity cost in the clinic. Opportunities to make adaptive replanning more cost-effective include incorporation of AI tools for volume delineation and/or treatment planning to reduce personnel time, as well as using daily cone beam CT images instead of a new CT simulation, when feasible.