Evaluating the Cost Effectiveness of Image Guided Partial Breast Irradiation Compared to Hypofractionated Whole Breast Irradiation

Abstract

Hypofractionated whole breast irradiation (HWBI) and accelerated partial breast irradiation (APBI) represent two adjuvant radiation therapy options following breast-conserving surgery. The purpose of this analysis is to examine the cost efficacy and costing of an external beam image guided APBI technique compared to HWBI. HWBI was defined as 40 Gy/15 fractions to the whole breast with or without a 10 Gy/5 fraction boost. APBI was 30 Gy/5 fractions per Livi et al and was evaluated as both IMRT and SBRT. The model included rates of local recurrence, distant metastases, survival, as well as acute toxicity. Reimbursement was based on Medicare 2017 reimbursement rates. A cost effectiveness analysis was performed using a payer model, as was a societal model that incorporated indirect costs. A costing analysis for each technique was also performed. Reimbursement (payor model) for HWBI with or without boost was $9,174/$7,476 while reimbursement for APBI was $6,529/$11,510 for IMRT and SBRT approaches respectively. Accounting for indirect costs, the total cost was $10,783/$8,750 for HWBI with and without boost and $7,133/$12,113 for APBI IMRT/SBRT. APBI delivered with IMRT had a higher total utility and lower cost, dominating HWBI with or without boost; as such a sensitivity analysis was not performed. APBI billed as SBRT was not cost-effective with a cost/QALY of $1,209,090/QALY and $3,058,181/QALY as compared to HWBI with or without a boost. With respect to costing, the cost associated with APBI delivery was $3,125 as compared to $4,589/$3,748 for HWBI with and without boost. Image-guided partial breast irradiation is cost effective compared to hypofractionated WBI. Delivered with IMRT, such an approach was less costly than hypofractionation with or without a boost. When evaluating the technique on a larger scale, this would translate into $3.7 million/$1.6 million cost savings per thousand patients who receive EBRT APBI as compared to HWBI with or without boost. Image guided APBI with IMRT should be considered a standard of care option in appropriately selected patients based on efficacy and value.