Cost-Effectiveness of Proton Therapy in Head-and-Neck Cancer

Abstract

Recent evidence suggests that proton therapy results in less toxicity for patients with head-and-neck cancer compared to conventional radiation modalities. Proton therapy adds upfront cost to treatment, though reducing toxicity could offset that cost and improve patient quality of life, which raises the question of cost-effectiveness. We hypothesized that treating head-and-neck cancer patients with proton therapy is cost-effective. We constructed a microsimulation cost-effectiveness model to simulate the costs, quality of life, and survival of patients with locally advanced oropharyngeal cancer treated with either proton therapy or intensity-modulated radiation therapy (IMRT). Estimations of acute and late toxicity, costs, quality of life (health utility), and survival were ascertained from the literature. We assumed patients treated with IMRT and proton therapy had similar disease control and survival rates, though risks of acute and late toxicity would vary. We calculated incremental cost-effectiveness ratios (ICER), with ICERs under $100,000 per quality-adjusted life years (QALY) considered cost-effective. We used one-way and probabilistic sensitivity analyses to determine factors that heavily influence cost-effectiveness and overall stability of the model. Proton therapy increased the total cost of care by $5,000, with a corresponding increase in 0.069 QALYs, leading to an ICER of $72,500 per QALY compared with IMRT. The model was most sensitive to assumptions about the costs and probability of long-term feeding tube. Our base-case model assumed that proton therapy reduced the need for a long-term feeding tube by 12%. If proton therapy reduced the need for a long-term feeding tube by 10% then proton therapy would no longer be considered cost-effective. Additionally, if the 3-month cost of a feeding tube decreased from $4,230 to $2,870 then proton therapy would not be cost effective. The model was not sensitive to assumptions about acute toxicity, xerostomia, or dysphagia. In a probabilistic sensitivity analysis proton therapy was cost-effective in 66% of iterations. Proton therapy could be considered cost-effective in oropharyngeal cancer, though the cost-effectiveness model was particularly sensitive to assumptions about long-term feeding tube use. Defining the value of proton therapy in head-and-neck cancer requires additional research clarifying the long-term quality of life benefits of this treatment modality.