Cost-effectiveness of intraoperative radiation therapy versus intensity-modulated radiation therapy for the treatment of early breast cancer: A disinvestment analysis

Background: Adjuvant radiotherapy represents a key component in curative-intent treatment for early-stage breast cancer patients. In last years, two accelerated partial breast irradiation (APBI) techniques are preferred for this population in our organization: electron-based Intraoperative radiation therapy (IORT) and Linac based External Beam Radiotherapy, particularly Intensity-modulated radiation therapy (IMRT-APBI). Recently published long-term follow-up data evaluating these technologies have motivated a health technology reassessment of IORT compared to IMRT. Methods We developed a Markov model to simulate health-state transitions from a cohort of women with early-stage breast cancer, after lumpectomy and adjuvant APBI using either IORT or IMRT techniques. The cost-effectiveness from a private health provider perspective was assessed from a disinvestment point of view, using life-years (LYs) and recurrence-free life-years (RFLYs) as measure of benefits, along with their respective quality adjustments. Expected costs and benefits, and the incremental cost-effectiveness ratio (ICER) were reported. Finally, a scenario analysis was performed to evaluate the cost-effectiveness if equipment maintenance costs are removed. Results IORT technology was dominated by IMRT in all cases (i.e., less benefits with greater costs), except when benefits were estimated as LYs, where no differences were found and therefore the ICER was undefined. Despite small differences were found regarding benefits, costs were considerably higher for IORT. In the scenario analysis without equipment maintenance costs, IORT was still dominated by IMRT. Conclusions For this cohort of patients, IMRT was, at least, non-inferior to IORT in terms of expected benefits, with considerably lower costs. As a result, IORT disinvestment should be considered, favoring the use of IMRT in these patients.