title: Cost-effectiveness of stereotactic radiosurgery with and without whole-brain radiotherapy for the treatment of newly diagnosed brain metastases.
abstract: OBJECTIVE
  Stereotactic radiosurgery (SRS) alone is increasingly used in patients with newly diagnosed brain metastases. Stereotactic radiosurgery used together with whole-brain radiotherapy (WBRT) reduces intracranial failure rates, but this combination also causes greater neurocognitive toxicity and does not improve survival. Critics of SRS alone contend that deferring WBRT results in an increased need for salvage therapy and in higher costs. The authors compared the cost-effectiveness of treatment with SRS alone, SRS and WBRT (SRS+WBRT), and surgery followed by SRS (S+SRS) at the authors' institution.
  
  
  METHODS
  The authors retrospectively reviewed the medical records of 289 patients in whom brain metastases were newly diagnosed and who were treated between May 2001 and December 2007. Overall survival curves were plotted using the Kaplan-Meier method. Multivariate proportional hazards analysis (MVA) was used to identify factors associated with overall survival. Survival data were complete for 96.2% of patients, and comprehensive data on the resource use for imaging, hospitalizations, and salvage therapies were available from the medical records. Treatment costs included the cost of initial and all salvage therapies for brain metastases, hospitalizations, management of complications, and imaging. They were computed on the basis of the 2007 Medicare fee schedule from a payer perspective. Average treatment cost and average cost per month of median survival were compared. Sensitivity analysis was performed to examine the impact of variations in key cost variables.
  
  
  RESULTS
  No significant differences in overall survival were observed among patients treated with SRS alone, SRS+WBRT, or S+SRS with respective median survival of 9.8, 7.4, and 10.6 months. The MVA detected a significant association of overall survival with female sex, Karnofsky Performance Scale (KPS) score, primary tumor control, absence of extracranial metastases, and number of brain metastases. Salvage therapy was required in 43% of SRS-alone and 26% of SRS+WBRT patients (p < 0.009). Despite an increased need for salvage therapy, the average cost per month of median survival was $2412 per month for SRS alone, $3220 per month for SRS+WBRT, and $4360 per month for S+SRS (p < 0.03). Compared with SRS+WBRT, SRS alone had an average incremental cost savings of $110 per patient. Sensitivity analysis confirmed that the average treatment cost of SRS alone remained less than or was comparable to SRS+WBRT over a wide range of costs and treatment efficacies.
  
  
  CONCLUSIONS
  Despite an increased need for salvage therapy, patients with newly diagnosed brain metastases treated with SRS alone have similar overall survival and receive more cost-effective care than those treated with SRS+WBRT. Compared with SRS+WBRT, initial management with SRS alone does not result in a higher average cost.
authors.affiliation: Departments of 1 Radiology and.
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Hall
authors.forename: James L
authors.initials: JL
authors.lastname: McGee
authors.forename: Mackenzie C
authors.initials: MC
authors.lastname: McGee
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Hall
authors.forename: David M
authors.initials: DM
authors.lastname: Neils
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Klopfenstein
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Elwood
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000556:secondary / Q000601:surgery; D003362:Cost-Benefit Analysis; D016371:Cranial Irradiation / Q000191:economics / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D017059:Models, Econometric; D018579:Patient Selection; D016016:Proportional Hazards Models; D016634:Radiosurgery / Q000191:economics* / Q000401:mortality; D011878:Radiotherapy / Q000191:economics* / Q000401:mortality; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000191:economics / Q000401:mortality
keywords: Gamma Knife; ICER = incremental cost-effectiveness ratio; KPS = Karnofsky Performance Scale; MVA= multivariate proportional hazards analysis; S+SRS = surgery + SRS; SRS = stereotactic radiosurgery; WBRT = whole-brain radiotherapy; cost analysis; cost-effectiveness; oncology; stereotactic radiosurgery; whole-brain radiotherapy