title: A cost-effectiveness and cost-utility analysis of radiosurgery vs. resection for single-brain metastases.
abstract: OBJECTIVE
  The median survival of well-selected patients with single-brain metastases treated with whole-brain irradiation and resection or radiosurgery is comparable, although a randomized trial of these two modalities has not been performed. In this era of cost containment, it is imperative that health-care professionals make fiscally prudent decisions. The present environment necessitates a critical appraisal of apparently equi-efficacious therapeutic modalities, and it is within this context that we present a comparison of the actual costs of resection and radiosurgery for brain metastases.
  
  
  METHODS
  Survival and quality of life outcome data for radiation alone or with surgery were obtained from two randomized trials, and radiosurgical results were obtained from a multiinstitutional analysis that specifically evaluated patients meeting surgical criteria. Only linear accelerator radiosurgery data were considered. Cost analysis was performed from a societal view point, and the following parameters were evaluated: actual cost, cost ratios, cost effectiveness, incremental cost effectiveness, cost utility, incremental cost utility, and national cost burden. The computerized billing records for all patients undergoing resection or radiosurgery for single-brain metastases from January 1989 to July 1994 were reviewed. A total of 46 resections and 135 radiosurgery procedures were performed. During the same time period, 454 patients underwent whole-brain radiation alone. An analysis of the entire bill was performed for each procedure, and each itemized cost was assigned a proportionate figure. The relative cost ratios of resection and radiosurgery were compared using the Wilcoxon rank sum test. Cost effectiveness of each modality, defined as the cost per year of median survival, was evaluated. Incremental cost effectiveness, defined as the additional cost per year of incremental gain in median survival, compared to the next least expensive modality, was also determined. To calculate the societal or national impact of these practices, the proportion of patients potentially eligible for aggressive management was estimated and the financial impact was determined using various utilization ratios for radiosurgery and surgery.
  
  
  RESULTS
  Both resection and radiosurgery yielded superior survival and functional independence, compared to whole brain radiotherapy alone, with minor differences in outcome between the two modalities; resection resulted in a 1.8-fold increase in cost, compared to radiosurgery. The latter modality yielded superior cost outcomes on all measures, even when a sensitivity analysis of up to 50% was performed. A reversal estimate indicated that in order for surgery to yield equal cost effectiveness, its cost would have to decrease by 48% or median survival would have to improve by 108%. The average cost per week of survival was $310 for radiotherapy, $524 for resection plus radiation, and $270 for radiosurgery plus radiation.
  
  
  CONCLUSIONS
  For selected patients, aggressive strategies such as resection or radiosurgery are warranted, as they result in improved median survival and functional independence. Radiosurgery appears to be the more cost-effective procedure.
authors.affiliation: Department of Human Oncology, University of Wisconsin Medical School, Madison, USA.
authors.forename: M
authors.initials: M
authors.lastname: Mehta
authors.forename: W
authors.initials: W
authors.lastname: Noyes
authors.forename: B
authors.initials: B
authors.lastname: Craig
authors.forename: J
authors.initials: J
authors.lastname: Lamond
authors.forename: R
authors.initials: R
authors.lastname: Auchter
authors.forename: M
authors.initials: M
authors.lastname: French
authors.forename: M
authors.initials: M
authors.lastname: Johnson
authors.forename: A
authors.initials: A
authors.lastname: Levin
authors.forename: B
authors.initials: B
authors.lastname: Badie
authors.forename: I
authors.initials: I
authors.lastname: Robbins
authors.forename: T
authors.initials: T
authors.lastname: Kinsella
mesh_terms: D001932:Brain Neoplasms / Q000191:economics* / Q000532:radiotherapy / Q000556:secondary / Q000601:surgery; D003362:Cost-Benefit Analysis / Q000379:methods; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006302:Health Services Research / Q000379:methods*; D006801:Humans; D019057:Quality-Adjusted Life Years; D016634:Radiosurgery / Q000191:economics*; D011878:Radiotherapy / Q000191:economics; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D014481:United States