title: Cost-effectiveness of stereotactic radiation, sublobar resection, and lobectomy for early non-small cell lung cancers in older adults.
abstract: OBJECTIVE
  Stereotactic ablative radiation (SABR) is a promising alternative to lobectomy or sublobar resection for early lung cancer, but the value of SABR in comparison to surgical therapy remains debated. We examined the cost-effectiveness of SABR relative to surgery using SEER-Medicare data.
  
  
  METHODS
  Patients age ≥66 years with localized (<5 cm) non-small cell lung cancers diagnosed from 2003-2009 were selected. Propensity score matching generated cohorts comparing SABR with either sublobar resection or lobectomy. Costs were determined via claims. Median survival was calculated using the Kaplan-Meier method. Incremental cost-effectiveness ratios (ICERs) were calculated and cost-effectiveness acceptability curves (CEACs) were constructed from joint distribution of incremental costs and effects estimated by non-parametric bootstrap.
  
  
  RESULTS
  In comparing SABR to sublobar resection, 5-year total costs were $55,120 with SABR vs. $77,964 with sublobar resection (P<0.001) and median survival was 3.6 years with SABR vs. 4.1 years with sublobar resection (P=0.95). The ICER for sublobar resection compared to SABR was $45,683/life-year gained, yielding a 46% probability that sublobar resection is cost-effective. In comparing SABR to lobectomy, 5-year total costs were $54,968 with SABR vs. $82,641 with lobectomy (P<0.001) and median survival was 3.8 years with SABR vs. 4.7 years with lobectomy (P=0.81). The ICER for lobectomy compared to SABR was $28,645/life-year gained, yielding a 78% probability that lobectomy is cost-effective.
  
  
  CONCLUSIONS
  SABR is less costly than surgery. While lobectomy may be cost-effective compared to SABR, sublobar resection is less likely to be cost-effective. Assessment of the relative value of SABR versus surgical therapy requires further research.
authors.affiliation: The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Smith
authors.affiliation: The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Jing
authors.initials: J
authors.lastname: Jiang
authors.affiliation: The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Joe Y
authors.initials: JY
authors.lastname: Chang
authors.affiliation: The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: James
authors.initials: J
authors.lastname: Welsh
authors.affiliation: Banner MD Anderson Cancer Center, Gilbert, AZ, United States.
authors.forename: Anna
authors.initials: A
authors.lastname: Likhacheva
authors.affiliation: The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
authors.affiliation: The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Stephen G
authors.initials: SG
authors.lastname: Swisher
authors.affiliation: Banner MD Anderson Cancer Center, Gilbert, AZ, United States.
authors.forename: Shervin M
authors.initials: SM
authors.lastname: Shirvani
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000191:economics* / Q000601:surgery*; D003362:Cost-Benefit Analysis / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008168:Lung / Q000601:surgery; D008175:Lung Neoplasms / Q000191:economics* / Q000601:surgery*; D008297:Male; D016634:Radiosurgery / Q000191:economics*; D016019:Survival Analysis; D016896:Treatment Outcome
keywords: Cost-effectiveness; Lobectomy; Lung cancer; SABR; SBRT; Sublobar resection