THE COST-EFFECTIVENESS OF ROUTINE POSTOPERATIVE RADIOTHERAPY AFTER SECTOR RESECTION AND AXILLARY DISSECTION FOR BREAST-CANCER STAGE-I - RESULTS FROM A RANDOMIZED TRIAL

Background. Cost-effectiveness of routine postoperative radiotherapy a fter breast-conserving surgery has not been prospectively evaluated ea rlier. In times of rationing of medical resources, valid assessments o f cost-effectiveness are important for rational allocation of resource s. Purpose: Cost and cost-effectiveness of routine postopera tive radi otherapy was calculated in a prospective randomized trial comparing se ctor resection plus axillary dissection with (XRT group) or without (n on-XRT group) postoperative radiotherapy in breast cancer stage I. Thr ee hundred eighty-one patients were included. After a median follow-up of five years 43 local recurrences, six of them in the XRT-group occu rred (P < 0.0001). No difference in regional and distant recurrence (P = 0.23) or survival (P = 0.44) was observed. Patients and methods. Di rect medical costs as well as indirect costs in terms of production lo st during the treatment period and travel expenses were estimated from data in the medical records and the national insurance registry of ea ch patient. Average costs of different treatment activities and measur es were estimated for the XRT-group and the non-XRT group respectively . From these estimates differences in costs and effectiveness between the groups were calculated and marginal cost-effectiveness ratios were estimated. For the construction of QALYs each life-year was quality-a djusted by a utility value depending on which health state the patient was considered to perceive, Results: Taking into account the cost of primary treatment, the cost of follow-up, the cost of treatment of a l ocal recurrence, travel expenses and indirect costs (production lost) excluding costs for treatment of regional and distant recurrence the c ost per avoided local recurrence at five years was SEK 337,727 ($ 44,4 38, pound 27,018). Adjustment for quality of life showed a cost for ev ery gained QALY to be SEK similar to 1.6 million, ($ 210,526, pound 12 8,000), range SEK 0.2-3.9 million ($ 26,315 - 513,158, pound 16,000 - 312,000). Conclusion. The cost of routine postoperative radiotherapy a fter sector:resection and axillary dissection in breast cancer stage I per avoided local recurrence and gained QALY is high. The cost per ga ined QALY show great variation depending on utility value: which in th is study was derived from external observers and not from the patients themselves. These results stress the importance of identifying risk f actors for local recurrence, better understanding of impact on quality of life of a local recurrence and adding cost evaluations to clinical trials in early breast cancer.