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Cost-Effectiveness Analysis of Upfront SBRT for Oligometastatic Stage IV Non–Small Cell Lung Cancer Based on Mutational Status

Kim, Hayeon PhD, DABR*; Vargo, John A. MD*; Ling, Diane C. MD*; Beriwal, Sushil MD, MBA*; Smith, Kenneth J. MD, MS

American Journal of Clinical Oncology: November 2019 - Volume 42 - Issue 11 - p 837–844
doi: 10.1097/COC.0000000000000608
Original Articles: Thoracic

Objectives: Current National Comprehensive Cancer Network (NCCN) guidelines support systemic therapy based on mutational status in stage IV non–small cell lung cancer (NSCLC), with stereotactic body radiation therapy (SBRT) reserved for oligoprogression. We aimed to evaluate the cost-effectiveness of the routine addition of SBRT to upfront therapy in stage IV NSCLC by mutational subgroup.

Materials and Methods: A Markov state transition model was constructed to perform a cost-effectiveness analysis comparing SBRT plus maintenance therapy with maintenance therapy alone for oligometastatic NSCLC. Three hypothetical cohorts were analyzed: epidermal growth factor receptor or anaplastic lymphoma kinase mutation-positive, programmed death ligand-1 expressing, and mutation-negative group. Clinical parameters were obtained largely from clinical trial data, and cost data were based on 2018 Medicare reimbursement. Strategies were compared using the incremental cost-effectiveness ratio with effectiveness in quality-adjusted life years (QALYs) and evaluated with a willingness to pay threshold of $100,000 per QALY gained.

Results: SBRT plus maintenance therapy was not cost-effective at a $100,000/QALY gained threshold, assuming the same survival for both treatments, resulting in an incremental cost effectiveness ratio of $564,186 and $299,248 per QALY gained for the epidermal growth factor receptor or anaplastic lymphoma kinase positive and programmed death ligand-1 positive cohorts, respectively. Results were most sensitive to the cost of maintenance therapy. A large overall survival gain with SBRT could potentially result in upfront SBRT becoming cost-effective. For the mutation-negative cohort, upfront SBRT was nearly cost-effective, costing $128,424 per QALY gained.

Conclusion: Adding SBRT to maintenance therapy is not a cost-effective strategy for oligometastatic NSCLC compared with maintenance therapy alone for mutation-positive groups. However, this should be validated via randomized trials.

*Department of Radiation Oncology, UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine

Clinical and Translational Science and Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA

The authors declare no conflicts of interest.

Reprints: Hayeon Kim, PhD, DABR, Department of Radiation Oncology, UPMC Hillman Cancer Center, Magee-Women’s Hospital, 300 Halket St., Pittsburgh, PA 15213. E-mail:

Online date: October 9, 2019

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