title: Single- versus multiple-fraction radiotherapy in patients with painful bone metastases: cost-utility analysis based on a randomized trial.
abstract: BACKGROUND
  Radiotherapy is an effective palliative treatment for cancer patients with painful bone metastases. Although single- and multiple-fraction radiotherapy are thought to provide equal palliation, which treatment schedule provides better value for the money is unknown. We compared quality-adjusted life expectancy (the overall valuation of the health of the patients) and societal costs for patients receiving either single- or multiple-fraction radiotherapy.
  
  
  METHODS
  A societal cost-utility analysis was performed on a Dutch randomized, controlled trial of 1157 patients with painful bone metastases that compared pain responses and quality of life from a single-fraction treatment schedule of 8 Gy with a treatment schedule of six fractions of 4 Gy each. The societal values of life expectancies were assessed with the EuroQol classification system (EQ-5D) questionnaire. A subset of 166 patients also answered additional questionnaires to estimate nonradiotherapy and nonmedical costs. Statistical tests were two-sided.
  
  
  RESULTS
  Comparing the single- and multiple-fraction radiotherapy schedules, no differences were found in life expectancy (43.0 versus 40.4 weeks, P =.20) or quality-adjusted life expectancy (17.7 versus 16.0 weeks, P =.21). The estimated cost of radiotherapy, including retreatments and nonmedical costs, was statistically significantly lower for the single-fraction schedule than for the multiple-fraction schedule ($2438 versus $3311, difference = $873, 95% confidence interval [CI] on the difference = $449 to $1297; P<.001). The estimated difference in total societal costs was larger, also in favor of the single-fraction schedule, but it was not statistically significant ($4700 versus $6453, difference = $1753, 95% CI on the difference = -$99 to $3604; P =.06). For willingness-to-pay between $5000 and $40 000 per quality-adjusted life year, the single-fraction schedule was statistically significantly more cost-effective than the multiple-fraction schedule (P< or =.05).
  
  
  CONCLUSIONS
  Compared with multiple-fraction radiotherapy, single-fraction radiotherapy provides equal palliation and quality of life and has lower medical and societal costs, at least in The Netherlands. Therefore, single-fraction radiotherapy should be considered as the palliative treatment of choice for cancer patients with painful bone metastases.
authors.affiliation: Department of Medical Decision Making, Leiden University Medical Center, The Netherlands. W.B.van_den_Hout@LUMC.NL
authors.forename: Wilbert B
authors.initials: WB
authors.lastname: van den Hout
authors.forename: Yvette M
authors.initials: YM
authors.lastname: van der Linden
authors.forename: Elsbeth
authors.initials: E
authors.lastname: Steenland
authors.forename: Ruud G J
authors.initials: RG
authors.lastname: Wiggenraad
authors.forename: Job
authors.initials: J
authors.lastname: Kievit
authors.forename: Hanneke
authors.initials: H
authors.lastname: de Haes
authors.forename: Jan Willem H
authors.initials: JW
authors.lastname: Leer
mesh_terms: D000328:Adult; D000368:Aged; D001859:Bone Neoplasms / Q000150:complications* / Q000191:economics / Q000532:radiotherapy* / Q000556:secondary; D003362:Cost-Benefit Analysis; D019583:Dose Fractionation, Radiation; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010146:Pain / Q000191:economics / Q000209:etiology*; D010166:Palliative Care / Q000191:economics* / Q000379:methods*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D011878:Radiotherapy / Q000191:economics / Q000379:methods; D016896:Treatment Outcome