Cost analysis comparing brachytherapy versus surgery for primary carcinoma of the tonsillar fossa and/or soft palate

Abstract

Purpose Locoregional control rates, late normal tissue sequelae, and functional outcome scores have not been different for tonsillar fossa and/or soft palate tumors treated by either brachytherapy (BT) or surgery in an organ function preservation protocol. For additional prioritizing in clinical decision-making, we focused on a comparison of the full hospital costs of the different treatment options. Methods and materials Between 1986 and 2001, tonsillar fossa and/or soft palate tumors were treated by external beam radiotherapy (EBRT) to the primary tumor and neck, followed by fractionated BT to the primary. Neck dissection (ND) was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, resection combined with postoperative EBRT was executed (surgery group; 86 patients). Locoregional control, disease-free survival, and overall survival were calculated according to the Kaplan-Meier method. The performance status scales, late side effects, and degree of xerostomia have been previously reported. This paper focused on the hospital and follow-up costs for the treatment groups EBRT and BT with or without ND compared with surgery followed by postoperative RT (PORT). Finally, these costs were also computed for future treatment strategies (e.g., better sparing of normal tissues by intensity-modulated RT [IMRT]). Results Locoregional control, disease-free survival, and overall survival rate at 5 years for patients treated with EBRT and BT with or without ND vs. surgery plus PORT was 80% vs. 78%, 58% vs. 55%, and 67% vs. 57%, respectively. The major late side effect was xerostomia. Dry mouth syndrome affected the BT group and surgery group equally. The total costs for all treatment groups were €14,262 (BT group), €16,628 (BT plus ND group), €18,782 (surgery plus PORT group), €14,532 (IMRT group), and €16,897 (IMRT plus ND group). Conclusion Excellent locoregional tumor control was observed with either modality, with no statistically significant differences in the incidence of the most noted side effect xerostomia. The total costs for BT were less than for surgery: €16,628 ($19,452) for EBRT plus BT plus ND vs. €18,782 ($22,074) for surgery plus PORT. To reduce the morbidity of xerostomia, we propose further optimizing our organ function preservation protocol by implementing IMRT as a more conformal, tissue-sparing, RT technique. This is of particular interest because the costs of IMRT plus ND (€16,897; $19,767) were not very different from those for BT plus ND (€16,628; $19,452) and were far less than the costs for surgery.