title: Cost-effectiveness analysis of neurocognitive-sparing treatments for brain metastases.
abstract: BACKGROUND
  Decisions regarding how to treat patients who have 1 to 3 brain metastases require important tradeoffs between controlling recurrences, side effects, and costs. In this analysis, the authors compared novel treatments versus usual care to determine the incremental cost-effectiveness ratio from a payer's (Medicare) perspective.
  
  
  METHODS
  Cost-effectiveness was evaluated using a microsimulation of a Markov model for 60 one-month cycles. The model used 4 simulated cohorts of patients aged 65 years with 1 to 3 brain metastases. The 4 cohorts had a median survival of 3, 6, 12, and 24 months to test the sensitivity of the model to different prognoses. The treatment alternatives evaluated included stereotactic radiosurgery (SRS) with 3 variants of salvage after recurrence (whole-brain radiotherapy [WBRT], hippocampal avoidance WBRT [HA-WBRT], SRS plus WBRT, and SRS plus HA-WBRT). The findings were tested for robustness using probabilistic and deterministic sensitivity analyses.
  
  
  RESULTS
  Traditional radiation therapies remained cost-effective for patients in the 3-month and 6-month cohorts. In the cohorts with longer median survival, HA-WBRT and SRS plus HA-WBRT became cost-effective relative to traditional treatments. When the treatments that involved HA-WBRT were excluded, either SRS alone or SRS plus WBRT was cost-effective relative to WBRT alone. The deterministic and probabilistic sensitivity analyses confirmed the robustness of these results.
  
  
  CONCLUSIONS
  HA-WBRT and SRS plus HA-WBRT were cost-effective for 2 of the 4 cohorts, demonstrating the value of controlling late brain toxicity with this novel therapy. Cost-effectiveness depended on patient life expectancy. SRS was cost-effective in the cohorts with short prognoses (3 and 6 months), whereas HA-WBRT and SRS plus HA-WBRT were cost-effective in the cohorts with longer prognoses (12 and 24 months).
authors.affiliation: Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina.
authors.forename: Samuel T
authors.initials: ST
authors.lastname: Savitz
authors.affiliation: Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Ronald C
authors.initials: RC
authors.lastname: Chen
authors.affiliation: Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: David J
authors.initials: DJ
authors.lastname: Sher
mesh_terms: D000368:Aged; D001932:Brain Neoplasms / Q000191:economics / Q000556:secondary* / Q000628:therapy*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D006624:Hippocampus / Q000528:radiation effects; D006801:Humans; D008390:Markov Chains; D018803:Models, Economic; D016634:Radiosurgery / Q000191:economics*; D016019:Survival Analysis; D016896:Treatment Outcome; D014916:Whole-Body Irradiation / Q000191:economics*
keywords: cognition disorders; computer-assisted radiotherapy; cost-effectiveness analysis; image-guided radiotherapy; secondary brain neoplasm