title: Establishing Cost-Effective Allocation of Proton Therapy for Breast Irradiation.
abstract: OBJECTIVE
  Cardiac toxicity due to conventional breast radiation therapy (RT) has been extensively reported, and it affects both the life expectancy and quality of life of affected women. Given the favorable oncologic outcomes in most women irradiated for breast cancer, it is increasingly paramount to minimize treatment side effects and improve survivorship for these patients. Proton RT offers promise in limiting heart dose, but the modality is costly and access is limited. Using cost-effectiveness analysis, we provide a decision-making tool to help determine which breast cancer patients may benefit from proton RT referral.
  
  
  METHODS
  A Markov cohort model was constructed to compare the cost-effectiveness of proton versus photon RT for breast cancer management. The model was analyzed for different strata of women based on age (40 years, 50 years, and 60 years) and the presence or lack of cardiac risk factors (CRFs). Model entrants could have 1 of 3 health states: healthy, alive with coronary heart disease (CHD), or dead. Base-case analysis assumed CHD was managed medically. No difference in tumor control was assumed between arms. Probabilistic sensitivity analysis was performed to test model robustness and the influence of including catheterization as a downstream possibility within the health state of CHD.
  
  
  RESULTS
  Proton RT was not cost-effective in women without CRFs or a mean heart dose (MHD) <5 Gy. Base-case analysis noted cost-effectiveness for proton RT in women with ≥1 CRF at an approximate minimum MHD of 6 Gy with a willingness-to-pay threshold of $100,000/quality-adjusted life-year. For women with ≥1 CRF, probabilistic sensitivity analysis noted the preference of proton RT for an MHD ≥5 Gy with a similar willingness-to-pay threshold.
  
  
  CONCLUSIONS
  Despite the cost of treatment, scenarios do exist whereby proton therapy is cost-effective. Referral for proton therapy may be cost-effective for patients with ≥1 CRF in cases for which photon plans are unable to achieve an MHD <5 Gy.
authors.affiliation: Department of Radiation Oncology, NYU School of Medicine, New York, New York.
authors.forename: Raymond B
authors.initials: RB
authors.lastname: Mailhot Vega
authors.affiliation: Department of Radiation Oncology, NYU School of Medicine, New York, New York.
authors.forename: Omar
authors.initials: O
authors.lastname: Ishaq
authors.affiliation: Radiation Oncology Program, Harvard University, Boston, Massachusetts.
authors.forename: Ann
authors.initials: A
authors.lastname: Raldow
authors.affiliation: Department of Radiation Oncology, NYU School of Medicine, New York, New York.
authors.forename: Carmen A
authors.initials: CA
authors.lastname: Perez
authors.affiliation: Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Rachel
authors.initials: R
authors.lastname: Jimenez
authors.affiliation: Cardiovascular Research Center, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Marielle
authors.initials: M
authors.lastname: Scherrer-Crosbie
authors.affiliation: Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Marc
authors.initials: M
authors.lastname: Bussiere
authors.affiliation: Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Alphonse
authors.initials: A
authors.lastname: Taghian
authors.affiliation: Department of Radiation Oncology, University of Texas Southwestern Medical Center, San Antonio, Texas.
authors.forename: David J
authors.initials: DJ
authors.lastname: Sher
authors.affiliation: Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts. Electronic address: smacdonald@partners.org.
authors.forename: Shannon M
authors.initials: SM
authors.lastname: MacDonald
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D001943:Breast Neoplasms / Q000532:radiotherapy*; D002404:Catheterization; D003327:Coronary Disease / Q000150:complications; D003361:Cost Allocation / Q000191:economics / Q000379:methods; D003362:Cost-Benefit Analysis; D020000:Decision Support Systems, Clinical; D005260:Female; D006321:Heart / Q000528:radiation effects*; D006801:Humans; D008017:Life Expectancy; D008390:Markov Chains; D008875:Middle Aged; D017059:Models, Econometric; D058958:Organs at Risk / Q000528:radiation effects; D017785:Photons / Q000627:therapeutic use; D061766:Proton Therapy / Q000009:adverse effects / Q000191:economics*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D011832:Radiation Injuries / Q000517:prevention & control; D011879:Radiotherapy Dosage; D012307:Risk Factors; D012680:Sensitivity and Specificity