title: Protons in head-and-neck cancer: bridging the gap of evidence.
abstract: OBJECTIVE
  To use Normal Tissue Complication Probability (NTCP) models and comparative planning studies to explore the (cost-)effectiveness of swallowing sparing intensity modulated proton radiotherapy (IMPT) compared with swallowing sparing intensity modulated radiotherapy with photons (IMRT) in head and neck cancer (HNC).
  
  
  METHODS
  A Markov model was constructed to examine and compare the costs and quality-adjusted life years (QALYs) of the following strategies: (1) IMPT for all patients; (2) IMRT for all patients; and (3) IMPT if efficient. The assumption of equal survival for IMPT and IMRT in the base case analysis was relaxed in a sensitivity analysis.
  
  
  RESULTS
  Intensity modulated proton radiation therapy and IMRT for all patients yielded 6.620 and 6.520 QALYs and cost €50,989 and €41,038, respectively. Intensity modulated proton radiation therapy if efficient yielded 6.563 QALYs and cost €43,650. The incremental cost-effectiveness ratio of IMPT if efficient versus IMRT for all patients was €60,278 per QALY gained. In the sensitivity analysis, IMRT was more effective (0.967 QALYs) and less expensive (€8218) and thus dominated IMPT for all patients.
  
  
  CONCLUSIONS
  Cost-effectiveness analysis based on normal tissue complication probability models and planning studies proved feasible and informative and enables the analysis of individualized strategies. The increased effectiveness of IMPT does not seem to outweigh the higher costs for all head-and-neck cancer patients. However, when assuming equal survival among both modalities, there seems to be value in identifying those patients for whom IMPT is cost-effective.
authors.affiliation: Department of Health Services Research, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands. bram.ramaekers@mumc.nl
authors.forename: Bram L T
authors.initials: BL
authors.lastname: Ramaekers
authors.forename: Janneke P C
authors.initials: JP
authors.lastname: Grutters
authors.forename: Madelon
authors.initials: M
authors.lastname: Pijls-Johannesma
authors.forename: Philippe
authors.initials: P
authors.lastname: Lambin
authors.forename: Manuela A
authors.initials: MA
authors.lastname: Joore
authors.forename: Johannes A
authors.initials: JA
authors.lastname: Langendijk
mesh_terms: D057186:Comparative Effectiveness Research; D003362:Cost-Benefit Analysis; D003680:Deglutition Disorders / Q000209:etiology; D018450:Disease Progression; D005240:Feasibility Studies; D006258:Head and Neck Neoplasms / Q000401:mortality / Q000532:radiotherapy*; D006801:Humans; D008390:Markov Chains; D058958:Organs at Risk / Q000528:radiation effects*; D010306:Parotid Gland / Q000528:radiation effects; D017785:Photons / Q000627:therapeutic use; D061766:Proton Therapy / Q000191:economics* / Q000379:methods / Q000401:mortality; D019057:Quality-Adjusted Life Years; D011879:Radiotherapy Dosage; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000191:economics* / Q000379:methods / Q000401:mortality; D012680:Sensitivity and Specificity; D035501:Uncertainty; D014987:Xerostomia / Q000209:etiology