title: Toxicity and cost-effectiveness analysis of intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy for postoperative treatment of gynecologic cancers.
abstract: OBJECTIVE
  To evaluate toxicity and cost-effectiveness of intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3DCRT) in the postoperative treatment of uterine and cervical cancer.
  
  
  METHODS
  Between 2000 and 2012, eighty patients at our institution received post-hysterectomy 3DCRT (46) or IMRT (34) for uterine or cervical cancer. Baseline characteristics, outcome, and ≥CTCAE grade 2 toxicities were compared between the two groups. Predictors of toxicity-free survival were identified. A decision analysis model was designed to capture individual health states at 1, 2, and 3 years after treatment. Micro-costing technique and estimated quality-adjusted life years (QALYs) were used to calculate incremental cost-effectiveness ratio (ICER).
  
  
  RESULTS
  Utilization of IMRT increased from 25% (2005-2007) to 75% (2008-2012). Recurrence-free and overall survival rates were not different between the two groups. Toxicity rates were reduced with IMRT versus 3DCRT (HR 0.42, p=0.04). Women who received IMRT had numerically lower rates of late gastrointestinal and genitourinary toxicity and significantly lower rates of late overall toxicity at 3 years (16% vs. 45%, p=0.04). On univariate analysis, IMRT was associated with decreased late toxicity (HR 0.43, p=0.04). Treatment costs were higher and toxicity costs were lower with IMRT. IMRT had an ICER of $235,233 (year 1), $114,270 (year 2), and $75,555 (year 3) per QALY gained.
  
  
  CONCLUSIONS
  IMRT is associated with reduced late overall toxicity compared to 3DCRT without compromising clinical outcome. IMRT is not cost-effective during the early chronic toxicity phase, but it becomes more cost-effective over time.
authors.affiliation: Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT, USA.
authors.forename: L Andy
authors.initials: LA
authors.lastname: Chen
authors.affiliation: Department of Family & Preventive Medicine, University of Utah, Salt Lake City, UT, USA.
authors.forename: Jaewhan
authors.initials: J
authors.lastname: Kim
authors.affiliation: Study Design and Biostatistics Center, Division of Epidemiology and Public Health, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Boucher
authors.affiliation: Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT, USA.
authors.forename: Breanne
authors.initials: B
authors.lastname: Terakedis
authors.affiliation: School of Medicine, University of Utah, Salt Lake City, UT, USA.
authors.forename: Britney
authors.initials: B
authors.lastname: Williams
authors.affiliation: Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA.
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Nickman
authors.affiliation: Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT, USA.
authors.forename: David K
authors.initials: DK
authors.lastname: Gaffney
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D003661:Decision Support Techniques; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D007044:Hysterectomy; D008875:Middle Aged; D011184:Postoperative Period; D019057:Quality-Adjusted Life Years; D018714:Radiotherapy, Adjuvant; D020266:Radiotherapy, Conformal / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000191:economics / Q000379:methods; D012042:Registries; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome; D014589:Utah; D002583:Uterine Cervical Neoplasms / Q000191:economics / Q000401:mortality / Q000532:radiotherapy / Q000601:surgery; D014594:Uterine Neoplasms / Q000191:economics / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery
keywords: Cost-benefit analysis; Endometrial neoplasms; Health care economics; Radiotherapy, conformal; Radiotherapy, intensity-modulated; Uterine cervical neoplasms