title: Evaluating radiotherapy options in breast cancer: does intraoperative radiotherapy represent the most cost-efficacious option?
abstract: BACKGROUND
  This study analyzed the cost-efficacy of intraoperative radiation therapy (IORT) compared with whole-breast irradiation (WBI) and accelerated partial-breast irradiation (APBI) for early-stage breast cancer.
  
  
  METHODS
  Data for this analysis came from 2 phase III trials: the TARGIT (Targeted Intraoperative Radiotherapy) trial and the ELIOT (Electron Intraoperative Radiotherapy) trial. Cost analyses included a cost-minimization analysis and an incremental cost-effectiveness ratio analysis including a quality-adjusted life-year (QALY) analysis. Cost analyses were performed comparing IORT with WBI delivered using 3-dimensional conformal radiotherapy (3D-CRT), APBI 3D-CRT, APBI delivered with intensity-modulated radiotherapy (IMRT), APBI single-lumen (SL), APBI multilumen (ML), and APBI interstitial (I).
  
  
  RESULTS
  Per 1000 patients treated, the cost savings with IORT were $3.6-$4.3 million, $1.6-$2.4 million, $3.6-$4.4 million, $7.5-$8.2 million, and $2.8-$3.6 million compared with WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I, respectively, with a cost decrement of $1.6-$2.4 million compared with APBI 3D-CRT based on data from the TARGIT trial. The costs per QALY for WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I compared with IORT were $47,990-$60,002; $17,335-$29,347; $49,019-$61,031; $108,162-$120,173; and $36,129-$48,141, respectively, based on data from the ELIOT trial. These results are consistent with APBI and WBI being cost-effective compared with IORT.
  
  
  CONCLUSIONS
  Based on cost-minimization analyses, IORT represents a potential cost savings in the management of early-stage breast cancer. However, absolute reimbursement is misleading, because when additional medical and nonmedical costs associated with IORT are factored in, WBI and APBI represent cost-effective modalities based on cost-per-QALY analyses. They remain the standard of care.
authors.affiliation: Department of Radiation Oncology, Summa Health System, Akron, OH. Electronic address: csshah27@hotmail.com.
authors.forename: Chirag
authors.initials: C
authors.lastname: Shah
authors.affiliation: Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri.
authors.forename: Shahed
authors.initials: S
authors.lastname: Badiyan
authors.affiliation: Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri.
authors.forename: Shariq
authors.initials: S
authors.lastname: Khwaja
authors.affiliation: Department of Family Medicine, Cleveland Clinic Foundation, Cleveland, OH.
authors.forename: Hardeepak
authors.initials: H
authors.lastname: Shah
authors.affiliation: Department of Oncology, Georgetown University School of Medicine, Washington, DC.
authors.forename: Ami
authors.initials: A
authors.lastname: Chitalia
authors.affiliation: Department of Oncology, Georgetown University School of Medicine, Washington, DC.
authors.forename: Anish
authors.initials: A
authors.lastname: Nanavati
authors.affiliation: Department of Plastic Surgery, Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH.
authors.forename: Neilendu
authors.initials: N
authors.lastname: Kundu
authors.affiliation: Department of Psychiatry, University of Florida, Gainesville, FL.
authors.forename: Vikram
authors.initials: V
authors.lastname: Vaka
authors.affiliation: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI.
authors.forename: Thomas B
authors.initials: TB
authors.lastname: Lanni
authors.affiliation: Michigan Healthcare Professionals/21st Century Oncology, Farmington Hills, MI.
authors.forename: Frank A
authors.initials: FA
authors.lastname: Vicini
mesh_terms: D001943:Breast Neoplasms / Q000191:economics* / Q000532:radiotherapy* / Q000601:surgery; D018270:Carcinoma, Ductal, Breast / Q000191:economics / Q000532:radiotherapy / Q000601:surgery; D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007430:Intraoperative Care / Q000191:economics*; D008408:Mastectomy; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D011879:Radiotherapy Dosage; D020266:Radiotherapy, Conformal / Q000191:economics*; D050397:Radiotherapy, Intensity-Modulated / Q000191:economics*; D016032:Randomized Controlled Trials as Topic; D015996:Survival Rate
keywords: Accelerated partial-breast irradiation; Breast conservation therapy; Cost efficacy; Intraoperative radiation; Whole breast irradiation