AUTHOR=Li Guo , Xia Yun-Fei , Huang Yi-Xiang , Okat Deniz , Qiu Bo , Doyen Jerome , Bondiau Pierre-Yves , Benezery Karen , Gao Jin , Qian Chao-Nan 

TITLE=Cost-effectiveness of using protons for breast irradiation aiming at minimizing cardiotoxicity: A risk-stratification analysis

JOURNAL=Frontiers in Medicine

VOLUME=Volume 9 - 2022

YEAR=2022

URL=https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2022.938927

DOI=10.3389/fmed.2022.938927

ISSN=2296-858X

ABSTRACT=Background: Incidental exposure of the heart to ionizing irradiation is associated with an increased risk of ischemic heart disease and subsequent fatality in breast cancer patients after radiotherapy. Proton beam therapy can limit the heart dose in breast irradiation to a negligible level. However, compared with conventional photon modality, proton breast irradiation is more expensive. In this study, we performed cost-effectiveness analyses to identify the type of patients who would be more suitable for protons.
Methods: A Markov decision model was designed to evaluate the cost-effectiveness of protons versus photons in reducing the risk of irradiation-related ischemic heart disease. Baseline evaluation was performed on a 50-year-old women patient without preexisting cardiac risk factor. Further, risk-stratification analyses for photon mean heart dose and preexisting cardiac risk were conducted on 40-, 50- and 60-year-old women patients under different proton cost and willingness-to-pay (WTP) settings.
Results: Using the baseline settings, the incremental effectiveness (protons versus photons) increased from 0.043 quality-adjusted life-year (QALY) to 0.964 QALY when preexisting cardiac risk increased to 10 times its baseline level. At a proton cost of 50,000 US dollars ($), protons could be cost-effective for ≤ 60-year-old patients with diabetes and ≤ 50-year-old patients with grade II-III hypertension at the WTP of China ($37,653/QALY); for ≤ 60-year-old patients with diabetes and ≤ 50-year-old patients with grade II-III hypertension or ≥ 2 major cardiac risk factors at a WTP of $50,000/QALY, and; for ≤ 60-year-old patients with diabetes, grade II-III hypertension or ≥ 2 major cardiac risk factors and ≤ 50-year-old patients with total cholesterol ≥ 240 mg/dL at a WTP of $100,000/QALY.
Conclusions: Patient’s preexisting cardiac risk status was a key factor affecting the cardiac benefits gained from protons and should therefore be a major consideration for the clinical decision of using protons; cost-effective scenarios of protons did exist in those patients with high risk of developing cardiac disease.