Comparing the cost-effectiveness of two brain metastasis treatment modalities from a payer's perspective: Stereotactic radiosurgery versus surgical resection

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Abstract

Objectives

This study aims to identify the cost-effectiveness of two brain metastatic treatment modalities, stereotactic radiosurgery (SRS) versus surgical resection (SR), from the perspective of Germany's Statutory Health Insurance (SHI) System.

Methods

Retrospectively reviewing 373 patients with brain metastases (BMs) who underwent SR (n = 113) and SRS (n = 260). Propensity score matching was used to adjust for selection bias (n = 98 each); means of survival time and survival curves were defined by the Kaplan–Meier estimator; and medical costs of follow-up treatment were calculated by the Direct (Lin) method. The bootstrap resampling technique was used to assess the impact of uncertainty.

Results

Survival time means of SR and SRS were 13.0, 18.4 months, respectively (P = 0.000). Medians of free brain tumor time were 10.4 months for SR and 13.8 months for SRS (P = 0.003). Number of repeated SRS treatments significantly influenced the survival time of SRS (R2 = 0.249; P = 0.006). SRS had a lower average cost per patient (€9964 – SD: 1047; Skewness: 7273) than SR (€11647 – SD: 1594; Skewness: 0.465), leading to an incremental cost effectiveness ratio of €−3740 per life year saved (LYS), meaning that using SRS costs €1683 less than SR per targeted patient, but increases LYS by 0.45 years.

Conclusion

SRS is more cost-effective than SR in the treatment of brain metastasis (BM) from the SHI perspective. When the clinical conditions allow it, early intervention with SRS in new BM cases and frequent SRS repetition in new BM recurrent cases should be advised.

Introduction

There are approximately 427,000 new cancer cases occurring annually in Germany. Men are affected 1.16 times more frequently than women. Compared to 1980, this number has increased by 35% for women and 80% for men. Age-standardized incidence rates have gone up by 15% and 23% respectively. The relative five year cancer survival rates have improved considerably from approximately 50% to 60% for women and from 40% to 55% for men [1]. With early diagnosis and more effective treatment prolonging survival, an increase in the occurrence of brain metastasis (BM) has been observed. 10–15% of patients suffer from BMs at first diagnosis of cancer [2] and during the course of the disease BMs appear in 20–40% of the patients [3], [4], [5], [6]. In Germany, this means 43,000–64,000 new patients developing BMs per year and a total of 300,000–550,000 patients with BMs. Besides the impact on the individual cases these figures show that BM is a serious and growing clinical and socioeconomic problem.

The health care system of Germany is characterized by a predominance of Statutory Health Insurance (SHI). Around 85% of the population is covered by SHI that pays for the vast majority of cancer therapeutic costs [7], [8]. As in most European countries, in Germany cost efficiency and reimbursement are more and more formalized in health technology assessments (HTA) and are of great importance in the decision making process about which costly therapies are worth paying for [8]. Recent studies on cost-effectiveness assessment (CEA) and the treatment of BM show higher cost-effectiveness for SRS than for SR [9], [10], [11], [12]. Despite of this outcome most HTA recommend more overall studies on CEA concerning therapies and combinations of therapies especially for the German health care system [13]. The scope of this study is the CEA of two treatment modalities which are SR and SRS from the perspective of Germany's SHI system.

Section snippets

Patient profile

All patients with single or multiple BM who received an initial SR or patients who had an initial SRS with the diameter of the largest tumor smaller than 3 cm, the number of tumors less than 10 on a magnetic resonance imaging (MRI) scan, but the total volume of the brain which was exposed to more than 10 Gy less than 100 cm3, were considered for this study. In the SR group, we excluded previous SRS, and leptomeningeal metastasis (LMM); prior SR and LMM were excluded in SRS group. Follow-up had to

Results

For the entire cohort, the median survival time was 10.2 months in the SR group compared to 14.0 months in the SRS group. The Log-rank test determined statistically significant differences between the two survival distribution curves (Table 1, P = 0.000). Improved survival probability of the entire cohort was identified by multivariate analysis of the Cox proportional regression with respect to potential predictors of survival, which found the statistically significant associations with the

Discussion

This study uses costs and clinical trial data from Germany to compare the cost-effectiveness of SRS and SR for the treatment of BMs, from the perspective of Germany's SHI System. The mean of medical costs from initial intervention to event occurrence (i.e. death or censored) was taken into account for the outcome effect determined for each of the two treatment arms. The outcome effect was measured as the LYS after the initial treatment (SRS in the SRS arm and SR in the SR arm) until event

Conclusion

SRS is a more cost-effective treatment modality than SR in the treatment of BM from the point of view of health insurance. When the clinical condition allows it, early intervention with SRS treatment in new cases of BM and frequently repeated SRS treatment in new cases of recurrent BM should be advised in order to prolong survival time.

Conflict of interest

None.

Acknowledgements

The authors would like to acknowledge the scholarship provided by the MOET of Vietnam and DAAD; grateful to Michael Bäumler (Berlin University of Technology), and three anonymous reviewers for valuable comments on an earlier draft of this paper. Any remaining errors are the responsibility of the authors.

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