Cost-Utility Analysis of RTOG 90-03: Phase III Randomized Study Comparing Altered Fractionation to Standard Fractionation Radiotherapy for Locally Advanced Head and Neck Squamous Cell Carcinoma

Heather Jones, MD
University of Pennsylvania Cancer Center
Last Modified: November 5, 2001

Presenter: A. Konski
Presenter's Affiliation: Toledo Radiation Oncology, Hickman Cancer Center, Adrian, MI
Type of Session: Scientific

Background
RTOG 90-03 a four-arm study that evaluated various fractionation schedules for the treatment of locally advanced head and neck cancer. This study attempts to determine the cost-effectiveness using cost-utility analysis of the four treatment regimens.

Materials and Methods

Quality adjusted survival was calculated for patients randomized to RTOG 90-03 by Q-TWiST methodology.

Determination of toxicity threshold was made by two of the co-authors. Patients were deemed to be in a toxicity state when the recorded toxicity was > grade 2 for skin, mucositis, salivary gland, esophageal, larynx, upper GI, and spinal cord or > grade 3 for bone and joints.

Time in toxicity was measured from onset of toxicity to time below toxicity threshold. Patients showing a complete response were considered in relapse at the time of recurrence.

The cost-utility analysis was performed comparing the three experimental fractionation schedules to the standard fractionation. Results are reported in cost/Quality Adjusted Life Year (QALY).

Results

Cost-utility analysis of the entire population assuming a utility of 1 for time spent in toxicity and relapse found accelerated fractionated radiotherapy with concomitant boost the most cost-effective regimen using actual cost data with $14,155.5/QALY.

Sensitivity analysis using a utility of .1 for time spent in toxicity, ( i.e. patients would not like to have any toxicity), found the standard fractionation arm dominated all treatment arms.

When the analysis was performed by gender and a utility of .6 was assumed for toxicity, hyperfractionated radiotherapy was the most cost-effective for males while accelerated hyperfractionated radiotherapy with split was the most cost-effective in females.

When a utility of 1 was assumed for toxicity, accelerated fractionated radiotherapy with concomitant boost was the most cost-effective in males with the results unchanged in females.

Author's Conclusions
This analysis finds accelerated fractionated radiotherapy to be the most cost-effective treatment regimen for patients with locally advanced head and neck cancer. The results differ between gender because of the time spent in toxicity and in relapse. The results will differ based on the utility patient's place on time spent in toxicity and relapse. Patients placing a higher utility on any survival will favor the more aggressive regimens. Conversely, patients placing a low utility on time spent in toxicity and relapse and thus not wanting to spend time in these health states, would have lower QALY's and thus treatment which is less cost-effective than standard therapy.

Clinical/Scientific Implications
As we attempt to be more aggressive in the treatment of locally advanced head and neck cancer, we must continue to monitor the cost in both dollars and cents and quality of life. To do so, we must develop stringent methodology to analyze data. This study is an excellent first step by the RTOG. I would hope in the next attempt to model quality adjusted survival that utility would be based on patient preferences and symptom distress scales and not on arbitrary values chosen by the physician.

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